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Interact CardioVasc Thorac Surg 2006;5:S187-S247. doi:10.1510/icvts.2006.0000S4 © 2006 European Association of Cardio-Thoracic Surgery AbstractsSuppl. 2 to Vol. 5 (September 2006)
001 - O NEOCHORDAE AS THE PRIMARY TECHNIQUE FOR REPAIR OF POSTERIOR MITRAL LEAFLET PROLAPSE A COMPARISON TO TRADITIONAL TECHNIQUES M.M. Yusuf, H. Luckraz, N. Masani, U.O. Von Oppel University Hospital of Wales, Cardiff, UK Objectives: Posterior mitral valve leaflet (PMVL) prolapse repair using CV5 Gore-Tex neochordae without leaflet resection was used as the primary method of repair. This technique is compared to traditional quadrangular leaflet resection. Methods: Prospective data were collected in 186 consecutive mitral valve repair patients; January 2003 to March 2006. Bileaflet repairs were required in 63 and PMVL only in 54. In the latter group 23 patients underwent repair using neochordae prepared to specific intraoperative measurements using a single suture technique and an annuloplasty ring without any resection (Group 1). The remaining 31 patients underwent more traditional quadrangular resection and an annuloplasty ring (Group 2). We compared immediate and short-term results between these groups. Results: Preoperative mitral regurgitation was severe in 83% (19/23) and 94% (29/31) respectively. Eleven patients in Group 1 (48%) and 4 patients Group 2 (13%) had prolapse of additional segments plus P2. Combined CABG was performed in 35% and 45% of patients respectively. Intraoperative post repair Trans Oesophageal Echo revealed trivial or less residual regurgitation in all patients in Group 1 and 94% of Group 2. At follow-up (FU) 96% of the patients in Group 1 (median FU 12.7 months, IR-5.1 to 19.7) and 94% in Group 2 (median FU 30.1 months, IR – 17.8 to 35.3) were in NYHA class 1 (P=0.74). Transthoracic Echo FU revealed trivial or no regurgitation Group 1–80% and Group 2–75% (P=0.76). There were no operative deaths and 1 late death in each group. Conclusions: Gore-Tex neochordae used as the primary repair technique for PMVL prolapse is reproducible and shows comparable results to traditional quadrangular resection/ reconstruction repair.
1Division of Cardiac Surgery, Second Faculty of Medicine, University of Rome La Sapienza, Rome, Italy; 2Division of Cardiology, Second Faculty of Medicine, University of Rome La Sapienza, Rome, Italy Objectives: To predict the impact of patient-prosthesis mismatch (PPM) assessed by previously published in vivo projected effective orifice area (EOA) on residual pulmonary hypertension (>40 mmHg) after mitral valve replacement (MVR). Methods: Forty consecutive patients (mean age 65±10 years, range 42–82) undergoing MVR had echocardiographic assessment of pulmonary pressure both pre- and postoperatively. A total of 33/40 patients (82.5%) had preoperative pulmonary hypertension (mean 51.1±12.6 mmHg). A multivariate analysis including demographic, operative and echocardiographic data was used to identify independent predictors of residual pulmonary hypertension. PPM was defined as an EOA indexed (EOAi) for body surface area <1.2 cm2/m2. Results: Patients had either biological or mechanical prostheses implanted, sizes ranging from 25 to 33 mm. PPM was found in 14/40 patients (35%). Overall, mean pulmonary pressure improved from 46±18 to 36±7 mmHg (P=0.03). A total of 16/33 patients (48%) with preoperative pulmonary hypertension had no normalisation of pulmonary pressure. Prosthesis characteristics did not differ between patients with and without residual pulmonary hypertension (median size: 29 vs. 27 mm, P=0.75; EOAi 1.43±0.19 vs. 1.41±0.30 cm2/m2, P=0.81). At multivariate analysis the only predictors of residual pulmonary hypertension (r2=41%; P=0.001) were preoperative pulmonary pressure (ß=0.40; P=0.021) and the presence of preoperative atrial fibrillation (ß=0.38; P=0.026). Conclusions: This study shows that PPM assessed by projected in vivo EOAi does not predict early residual pulmonary hypertension after MVR. Normalisation of pulmonary pressure was related with the severity of preoperative pulmonary hypertension supporting the opportunity of an early intervention. A longer-term follow-up is needed to assess the influence of PPM on pulmonary pressure.
1Cardiovascular Surgery Inselspital, Bern, Switzerland; 2Cardiology Inselspital, Bern, Switzerland Objectives: Tissue engineering represents an attractive approach for the treatment of congestive heart failure (CHF). We designed a biodegradable contracting tissue based on a collagen/matrigel and skeletal muscle cells. The aim of the study was to investigate the functional effect of ESMG cardiac implantation after myocardial infarction (MI). Methods: ESMGs were synthesised by mixing rat tail collagen (2 mg/ml), matrigel (2 mg/ml) and skeletal muscle cells (1 million). Two weeks post LAD ligation, animals were randomised in 3 groups: ESMG implantation at the surface of the infracted area using fibrin glue (n=8), fibrin glue deposition only (n=6), sham operation (n=4). Echocardiography was performed 4 weeks later before animals were sacrificed and histology and immunostaining were carried out. Results: Cohesive 3-D patches formed within one week. Cell death was less than 1%. Cell number stayed constant (1.2±0.1 million; 1.1±0.3; 1.2±0.5 at days 2, 5 and, 7 respectively), myoblasts differentiated into randomly oriented myotubes. Four weeks post-implantation, ESMGs were partially degraded and presented dense cellular organisation with neovascularisation as confirmed by smooth muscle actin staining. Mean fractional shortening (FS) was significantly increase in the ESMG implanted group (41%±8 post-implantation vs. 31%±6 pre-implantation, P<0.05). Pre- and post-implantation FS were however not different in the sham-operated and the fibrin-treated animals (respectively: 34%±7 vs. 35%±4 and 33%±5 vs. 35%±3). Conclusions: We demonstrate that ESMG implantation allows a significant functional effect on infarcted hearts. Thus, ESMGs represent promising three-dimensional artificial contractile tissues for cardiac repair.
1Department of Cardiovascular Surgery Heart Centre Brandenburg, Bernau, Germany; 2Institute of Medical Physics and Biophysics Charite, Berlin, Germany Objectives: Various techniques of stentless aortic valve implantation with or without wall components exist. However, haemodynamic performance may differ. We investigated the in-vitro performance of stentless valves with or without aortic wall removal mimicking root versus subcoronary implantation. Methods: Glutaraldehyde-preserved stentless aortic valves (gpSVG) (Köhler Medical), cryo-preserved human homografts (cpHG), cryo-preserved xenografts (cpXG), and fresh xenografts (fXG) of 21, 23, and 25 mm were used. Valves were mounted as full roots or trimmed in a mock circuit and were submitted to physiologic haemodynamic conditions (CO 4.9 l/min). Mean transvalvular gradient (TVG, mmHg) was measured. Distensibility was quantified using end-systolic Backflow Volume (BV, ml). Function was visualised by means of a high-speed camera (1000 frames/s). Results: Glutaraldehyde-preserved stentless valves exhibited higher TVG than cryo-preserved or fresh substitutes. After trimming, cpHG, cpXG, and fXG demonstrated a marked reduction of TVG (cpHG: 7.7–5.4 mmHg; cpXG: 6.9–4.5 mmHg; fXG: 8.0–5.4 mmHg). In contrast, after trimming gpSVG exhibited a significant increase of TVG (8.4–9.3 mmHg). BV remained rather constant in all valves of all types and sizes. Visualisation indicated maintained distension of all valves and types of all sizes after trimming. Conclusions: In fresh and cryo-preserved grafts aortic wall trimming resulted in significantly improved systolic performance while glutaraldehyde-preserved stentless valves demonstrated systolic impairment after wall resection. Subcoronary implantation of fresh or cryo-preserved aortic valves may therefore be preferred instead of the full root or mini-root technique. In contrast, glutaraldehyde-preserved stentless valves are dependent on wall suspension and may therefore be implanted as a root.
Division of Cardiovascular Thoracic and Paediatric Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Objectives: Evaluate distensibility of the aortic root and function of the aortic valve after aortic root replacement using valve sparing procedure. Methods: Between October 1999 and February 2006, valve sparing aortic root replacement was performed in 33 patients with a diagnosis of annuloaortic ectasia (AAE) and aortic valve insufficiency. We performed reimplantation type of valve-sparing procedure with a tube graft (n=10) or a valsalva graft (n=23). Echocardiographic studies were performed 6 months after the operation comparing with valsalva graft (Group V, n=15), tube graft (Group T, n=5), and normal control (Group C, n=5). Percent changes in radius (PCR) were measured as indices of distensibility and rapid valve opening velocity (RVOV /HR (mm/s/min)) and rapid valve closing velocity (RVCV/HR (mm/s/min)) were examined in each group. Results: Root distensibility of sinus PCR in Group V (4.44±2.53) was significantly preserved compared with Group T (1.91±1.19) (P=0.003) and had no significant difference compared with Group C (7.27±1.87). RVOV/HR in Group T was highest among three groups (T: 48.2±6.23, V: 34.8±12.8, C: 33.7±9.6). Conclusions: Sinus distensibility of the valsalva graft was well preserved. Valve-opening characteristics with valsalva graft were identical normal. Aortic valve function is more preserved in valsalva graft.
007 - I ATHEROSCLEROSIS PROGRESSION AFTER PRIMARY CABG: GENE POLYMORPHISMS AS RISK FACTORS FOR ADVERSE EVENTS S. Eifert1, P. Lohse2, A. Rasch1, L. deVries1, G. Nollert1, B. Reichart1 1Department of Cardiac Surgery, Ludwig Maximilians University, Munich, Germany; 2Institute of Clinical Chemistry, Ludwig Maximilians University, Munich, Germany Objectives: Progression of coronary artery disease (CAD) after primary coronary artery bypass grafting (CABG) is frequent and leads to recurrent angina, myocardial infarction, and the need for reinterventions. We hypothesised that classical risk factors of atherosclerosis as well as genetic dispositions may be associated with the progression of CAD. Methods: We investigated 192 patients (18% female, age: 59.2±8.4 years) who had primary CABG at our institution more than 5 years ago. Progression of CAD was defined as the need for reoperations (n=88; 46%), reinterventions (n=58; 30%), or angina at follow-up (n=89; 46%). Gene polymorphisms of the angiotensine metabolism, lipid metabolism (Apolipoprotein E, hepatic lipase, cholesteryl ester transfer protein), coagulation (platelet activator inhibitor-I, prothrombin, activated protein C resistance), and NO donor system (endothelial NO synthase) were determined. Results: Classical risk factors of atherosclerosis (diabetes, smoking history, hypertension, hyperlipidaemia) at the time of primary CABG did not correlate with CAD progression. Single polymorphisms (i.e. angiotensin II type 1 receptor, eNos, ApoE) provided limited information on the reintervention rate. Construction of a gene risk profile facilitated to discriminate among patients with a fast and slower progression of their CAD with respect to all endpoints (P=0.008). Conclusions: Single gene polymorphisms of patients after primary CABG permit a limited prognosis for the progression of CAD. However, gene risk profiles allow risk stratification and may help to understand the pathophysiology of aggressive CAD and to individualise secondary prevention. Further gene polymorphisms have to be investigated to improve this new concept.
1Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany; 2Institute of Circulatory Research, German Sport University, Cologne, Germany Objectives: STAT5 has been indicated to play a protective role in myocardial ischemia-reperfusion (I/R). We investigated the activation of STAT5 in patients subjected to cardioplegic arrest (CA) on cardiopulmonary bypass (CPB) and the impact of the antioxidant N-Acetylcysteine (NAC) on STAT5 regulation. Methods: In 32 CABG patients (66±9 [S.D.] years, 7 women and 25 men) we collected transmural LV biopsies prior to CPB (baseline) and at CPB-end. Patients were randomised in a double-blind fashion to receive either placebo (n=17) or NAC (100 mg/kg into CPB prime followed by infusion at 20 mg/kg/h; n=15). LV specimens were immuno-cytochemically stained against STAT5. Staining was quantitatively determined using densitometry and the number of positive capillaries per viewfield (cpv) was counted. Results: At CPB-end STAT5 was unchanged in both cardiac myocytes and endothelial cells of controls compared to baseline (14.7±3.8 vs. 13.0±3.1 and 129.3±66.9 vs. 135.7±77.8 cpv, P>0.05, respectively). However, STAT5 levels were 10-fold increased in endothelial cells compared to cardiac myocytes. NAC had no effect on STAT5 activation either in cardiac myocytes or in endothelial cells compared to controls. Conclusions: Our data show that STAT5 is activated in endothelial cells but not in cardiac myocytes in patients subjected to CA on CPB. However, STAT5-activity post I/R is unchanged in both cardiac myocytes and endothelial cells. Antioxidant treatment with NAC has no effect on STAT5 regulation.
1Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France; 2Hopital Cardiologique Louis Pradel, Lyon, France Objectives: Continuous flow in Fontan circulation is responsible for degradation of pulmonary artery (PA) endothelial function. The objective of this study was to compare, in an animal model, the impact on the PA system of continuous flow in relation to pulsed flow and to show the usefulness of pulsatility. Methods: Creation of three groups of 5 pigs, a sham group, a non-pulsed group and a group with micropulsatility and kept alive for three months. Comparative study was undertaken between the groups and between the right and left lung of each group, of haemodynamic and pulmonary vasorelaxation and vasoconstriction functional changes. A western blot analysis of endothelial nitric oxide synthase (eNOS), was done between the right pulmonary (RP) endothelium artery of each group. Results: The harmful effect of the non-pulsed regimen of RP artery of non-pulsed group by decreasing shear stress was reflected on the RP hypertension (P<0.0001) and on increase in RP resistance (P<0.0015). Response to nitric oxide (NO) was preserved but vasorelaxation to acetylcholine and ionophoric calcium dropped spectacularly (between the non-pulsed group and the sham group: P<0.002). Norepinephrine contraction was increased on the right in comparison with the left side (P<0.001). The relative value for eNOS protein levels was decreased with the non-pulsed group (P<0.05) and normal in the pulsed group. Conclusions: Micropulsatility attenuated the degree of PA hypertension but didn't prevent the degradation of acetylcholine and ionophoric calcium endothelial relaxation. Preservation of the response to NO regardless of the group enables it to be used to avoid increased PA resistance.
1Dokuz Eylul University School of Medicine, Department of Cardiovascular Surgery, Izmir, Turkey 2Dokuz Eylul University School of Medicine, Department of Histology, Izmir, Turkey; 3Dokuz Eylul University School of Medicine, Department of Pharmacology, Izmir, Turkey Objectives: Intimal hyperplasia and proliferation of smooth muscle cells play major role in stenosis occurring after vascular interventions. We investigated the inhibitory effect of adenosine (9-beta-0-ribofuranosyladenine) in the prevention of this pathology in the anastomoses carried out on the carotid artery of rabbit. Methods: Twenty-eight randomised, male, New Zealand type of rabbits were used. Their right carotid arteries were transsected and anastomosed by using 8/0 polypropylene sutures. Group A was the control group. Subcutaneous adenosine was used as 1 mg/kg-day to groups B, C and D for 3, 7 and 21 days, respectively. After 28 day, both anastomosed and contralateral carotid arteries were excised. Digital calculations for luminal diameter, luminal surface area, ratio of the surface areas of intima to media were made. The results are evaluated by using one-way ANOVA, posthoc-LSD and Mann Whitney U tests. Results: Luminal diameter measurements were wider in Group D than both Group A (P<0.0001) and Group B (P<0.001). Luminal areas of Group D was larger than Group A (P<0.0001), Group B (P<0.012) and Group C (P<0.012). When ratios of the surface areas of intima to media were compared, Group D had less intimal hyperplasia than both Group A and B. There was no difference between Groups D and C in this regard. No statistical significance was observed with regards to all parameters between control groups. Conclusions: Adenosine constitutes a further area of investigation by its beneficial effects on preventing intimal hyperplasia and proliferation of smooth muscle cells, in the subject of increasing patency rates after vascular interventions.
Medical University of Vienna, Vienna, Austria Objectives: Re-constitution of blood supply is crucial to rescue myocardial tissue following infarction. Skeletal myoblast transplantation is an attractive alternative in the repair of irreversibly damaged myocardium in ischemic heart failure. However, the majority of transplanted myoblasts undergo apoptosis due to inadequate blood supply. This study addressed this issue. Methods: Three weeks following myocardial infarction, rats developed heart failure and received intramyocardial injections of Ringer's solution, unmodified CSF-1, or autologous myoblasts transfected with CSF-1, VEGF, bFGF, and Ang-1 or with the latter combination supplemented with Ang-2. Real-time RT-PCR was used to measure gene expression, immunocytochemistry to analyze myoblast and macrophage tissue distribution and a Cytoscan(r) OPS imaging device was used to capture in vivo images of the vasculature. Results: The mRNA expression of angiogenic factors increased significantly (P<0.001). Vascular density was enhanced in all rats treated with modified myoblasts compared to other groups (P<0.001). Importantly, rats treated with CSF-1, VEGF, bFGF, Ang-1 and Ang-2 had a functional vascular network with increased vascular diameters compared to other groups (P<0.001). Increased macrophage recruitment and incorporation into vessel walls was observed for both treatment groups, but not in Ringer's solution (P<0.001) or unmodified myoblast groups (P<0.001). Conclusions: Transplantation of genetically modified myoblasts may represent a novel strategy in the treatment of ischemia-induced heart failure by induction of a functional vascular network and enhancement of myoblast survival.
1University of Patras Medical School, Patras, Greece; 2Nottingham City Hospital, Nottingham, United Kingdom; 3St James Hospital, Dublin, Ireland Objectives: Experimental angioscopic and pathological study that set off to investigate whether weaning by mode or by augmentation produces more aortic intimal trauma. Methods: An artificial pulsatile pump was used and an intact porcine aorta was incorporated into the circuit with the inflow at the aortic valve and the outflow at the right common iliac artery. Direct angioscopic images of the interior of the aorta were obtained. Keeping steady haemodynamic conditions, an ‘aortic impact score’ was calculated taking into account angioscopic observational variables and biopsies of the aorta at 30 min, 6 and 12 h following weaning by mode versus weaning by augmentation. Results: Endoscopically the balloon describes a complex movement. There is a ‘whipping’ effect of the balloon shaft on the lateral aortic wall. This appears to be prominent in 1:3 mode. The aortic impact score at 0.5 h during the experiments was: (1) When weaning by mode: (a) 1:1 3.3±0.6, 4.0±1.0 and 4.3±0.6; (b) 1:2 4.7±0.6, 6.7±0.6 and 7.0±0.0; (c) 1:3 8.7±0.6, 11±1.0 and 11.7±0.6. (2) Weaning by augmentation: (a) 75%, 2.3±0.6, 2.7±0.6 and 3.0±0.0; (b) 50%, 1.3±0.6, 1.3±0.6 and 1.7±0.6. An increasing score was observed while weaning by mode. For all pairwise comparisons between the two types of weaning, the differences were statistically significant (ANOVA test). Conclusions: It appears that weaning by mode produces more aortic intimal trauma. 1:3 mode produces marked intimal disruption that worsens with time.
1Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria; 2Department of Cardiothoracic Surgery, Vienna Medical University, Vienna, Austria; 3Institute of Pharmacology and Toxicology, University of Vienna, Vienna, Austria; 4Innovacell Biotechnology, Innsbruck, Austria; 5Institute of Clinical Biochemistry, Innsbruck Medical University, Innsbruck, Austria; 6Department of Haematology, Innsbruck Medical University, Innsbruck, Austria Objectives: Autologous skeletal myoblast transplantation can partially replace infarcted myocardium provided that the injected cells survive in large numbers in the host. Survival of the transplanted cells remains quite low in a setting of chronic myocardial ischemia. We investigated the effect of angiopoietic progenitors delivery in the border zone on the survival of transplanted skeletal myoblasts in chronic ischemic heart failure. Methods: Ischemic heart failure was induced by LAD-ligation in nude rats. A. 106 YFP-labelled homologous skeletal myoblasts (SM) or B. 106 YFP-labelled skeletal myoblasts and 106 DiI-labelled human derived AC-133+ cells (Comb) were injected in the infarct and peri-infarct area, respectively four weeks after infarction. Survival of skeletal myoblasts was assessed by means of confocal microsopy and evaluation of skeletal muscle fast myosin expression by rt-PCR. Apoptotic rates and capillary density were evaluated by means of immunohistochemistry. Results: Injection of angiopoietic progenitor cells in the border zone resulted in improved survival of SM in the infarct area (Comb: 52±13 vs. SM: 31±9/mm2, P=0.007). This effect was confirmed by increased expression of skeletal muscle fast myosin gene in the infarcted myocardium (Comb: 1.11±0.32x106 vs. SM: 0.63±0.21x106, P=0.004). Apoptotic index among viable SM injected in the infarct zone was significantly lower in animals treated by combined cell therapy (Comb: 0.53±0.12 vs. SM: 0.76±0.19, P=0.013). Assessment of capillary density in the infarct scar and the border zone revealed increased neoangiogenesis after combined cell transplantation (Comb: 10.4±2.3 vs. SM: 5.7±1.7, P=0.002). Conclusions: Combined transplantation of angiopoietic progenitor cells in the border zone and SM in the infarct scar improves myoblast survival and attenuates apoptosis by enhancing angiogenesis in chronic ischemic heart failure.
Hiroshima University School of Medicine, First Department of Surgery, Hiroshima, Japan Objectives: Previous studies indicated that high-dose intravenous edaravone (3–10 mg/kg) protects against ischemic spinal cord injury. This study is aimed to examine the efficacy of edaravone injected into the aorta. Methods: Spinal cord ischemia was induced in rabbits by direct aortic cross-clamping (below the renal artery and above the bifurcation) for 15 min at normothermia. In Group A (n=6), 3 mg/kg of edaravone was injected into the clamped segment of aorta. In Group B (n=6) and Group C (n=6), 1 mg/kg of edaravone and saline was injected, respectively, in the same manner. Neurological function was assessed at 8, 24, 48 h and 7 days after reperfusion with Tarlov score. The spinal cord was histologically examined at 7 days with haematoxylin-eosin staining and TUNEL method. Results: Tarlov score was 4 at every measurement point in Group A and Group B, whereas it dropped to 0 or 1 at 7 days in Group C. Mean score was significantly higher at 7 days in the former two groups (4.0, 4.0, and 0.17, respectively, P<0.0001). The number of intact motor neurons was significantly greater in Group A and Group B than in Group C (26.9, 24.5, and 8.6, respectively, P<0.0001) with reduced number of necrotic motor neurons in the former two groups. However TUNEL reaction was negative for apoptotic neurons. There was no significant difference between Group A and Group B. Conclusions: Low dose intraaortic edaravone prevents immediate neurological injury by reducing neuronal necrosis as well as delayed neurological injury at 7 days.
015 - O CLINICAL OUTCOME OF PATIENTS 20 YEARS AFTER FONTAN OPERATION – EFFECT OF FENESTRATION ON LATE MORBIDITY M. Ono, D. Boethig, H. Goerler, M. Lange, M. Westhoff-Bleck, T. Breymann Hannover Medical School, Hannover, Germany Objectives: The Fontan operation has been proposed as definitive palliation for hearts with complex univentricular anatomy, but late morbidity is still a matter of concern. This study evaluates the late outcome in patients with Fontan circulation. Methods: We included 121 consecutive patients that underwent Fontan operation between 1984 and 2004. Modifications of Fontan operation included atriopulmonary anastomosis (APA; n=28), total cavopulmonary connection (TCPC; n=63), and fenestrated TCPC (f-TCPC; n=30). Mean age was 5.8±0.5 years. Post operative mortality, morbidity, haemodynamics, and somatic development were analyzed. Results: Actuarial survival was 87% at 20 years. There were 10 early deaths, 5 late deaths, and 2 take-downs followed by successful conversion and heart transplantation. Among 108 early-survivors, 19 underwent reoperation, including 3 conversions of APA to TCPC. Freedom from reoperation or intervention was 76 and 34% at 20 years. Freedom from tachyarrhythmias or pacemaker implantation was 23 and 77% at 20 years. Heterotaxy and atrioventricular valve anomaly were risk factors for late failure and tachyarrhythmias. Patients with f-TCPC and patients with APA who developed collaterals, showed low incidence of late tachyarrythmias. Postoperative sinus node dysfunction or tachyarrhythmias was associated with significantly lower cardiac index. Somatic development was gradually compensated after Fontan operation. Weight normalised completely 15 years postoperatively. Conclusions: Long-term survival after Fontan procedure is encouraging, but late morbidity remains suboptimal. During follow-up, emerging complications should be managed by surgical and interventional procedures. Fenestration in Fontan circulation provided better cardiac output and lower incidence of tachyarrhythmias, suggesting benefits of fenestration for late outcome.
1National Cardiovascular Centre, Suita, Japan; 2Royal Brompton Hospital, London, UK Objectives: To determine whether preoperative small pulmonary artery could affect the midterm results of Fontan operation. Methods: Between 1992 and 2004, Fontan operation was done in 54 patients having a preoperative pulmonary artery index less than 250 mm2/m2 (Group S, minimum index: 104 mm2/m2). We retrospectively reviewed a consecutive series of these patients, and evaluated midterm Fontan circulation by postoperative catheterisation, hormonal and exercise tolerance test data, and compared it with that of 67 patients who had a larger pulmonary artery index and underwent Fontan operation during the same period (Group L). Results: There was neither early nor late mortality. The latest catheter examinations, at 2.8±2.7 postoperative years, showed a significantly decreased pulmonary artery index in both groups as compared with a preoperative index (Group S: 198±37 to 176±49 mm2/m2, P=0.0082, Group L: 360±94 to 266±89 mm2/m2, P<0.0001). However, the decreases were significantly smaller in Group S (-21±57 vs. –91±110 mm2/m2, P<0.0001). Moreover, there were no significant differences between the two groups regarding other circulatory parameters such as mean pulmonary artery pressure (Group S vs. Group L; 9.8±1.7 vs. 10.3±2.5 mmHg, P=0.2629), cardiac index (3.0±0.7 vs. 3.0±0.6 l/min/m2, P=0.7613), BNP concentration (19.4±15.6 vs. 28.3±37.2 pg/ml, P=0.1231) and peak VO2 (24.8±4.5 vs. 24.0±6.3 ml/kg/min, P=0.7246). Conclusions: Pulmonary artery size decreased after Fontan operation, but the decrease was significantly bigger in those with a larger preoperative pulmonary artery size. In patients having a small pulmonary artery size, the midterm results of the Fontan operation were favourable and not suboptimal compared with those in patients with a larger pulmonary artery size.
Department of Paediatric Cardiac Surgery, Polish American Children's Hospital, Collegium Medicum Jagiellonian University, Cracow, Poland Objectives: The causes of coagulation abnormalities and thromboembolic complications during staged Fontan approach in patients with single ventricle remain unclear. This study was designed to evaluate the coagulation profile in the early postoperative period after hemi-Fontan and Fontan procedures with relationship to liver function and haemodynamic variables. Methods: The prospective study on 43 patients after hemi-Fontan (Group 1) and 37 patients after Fontan procedure (Group 2) was carried out. Coagulation profile (factor VII, factor VIII, ATIII, fibrinogen, prothrombin), liver function (total serum protein, albumin, AST, ALT, bilirubin) and haemodynamic variables were assessed on postoperative day 1 and 5 and compared to preoperative measures. Results: Factor VIII concentration was significantly higher on 1st postoperative day in both groups. On postoperative day 5 the concentration of factor VIII was significantly decreased in Group 1 whereas constant in Group 2. The concentration of factor VII, ATIII, fibrinogen and prothrombin was significantly decreased on 1st and increased on 5th postoperative day after both hemi-Fontan and Fontan procedure. The increase in bilirubin concentration was more distinctive after Fontan operation (P=0.003) with lower AST in this group (P<0.0001). The single ventricle function, pO2 and central venous pressure had significant influence on factor VIII (P=0.034), factor VII (P=0.012), ATIII (P=0.006) and prothrombin (P=0.024) concentration in Group 2 with no significant influence in Group 1. Conclusions: The distinctive causes of coagulation abnormalities during staged Fontan approach are haemodynamic changes and temporary liver dysfunction. Elevated concentration of factor VIII and significant influence of haemodynamics on coagulation profile could contribute to postoperative thromboembolic complications.
Shizuoka Children Hospital, Shizuoka, Japan Objectives: The moderate/severe tricuspid regurgitation (TR) was one of the important risk factors of outcome in Norwood procedure. We have started to evaluate tricuspid valve (TV) by echo cardiogram more precisely and manage TR even if performing stage I Norwood. Methods: We reviewed all patients, (TR: moderate/severe=10, non-TR: mild/trivial=19) who underwent Stage I Norwood with ventricle to pulmonary artery conduit (RV-PA) between January 2001 and March 2007. Results: The median age was 4 days (TR: 3, non-TR: 4) and median weight was 2.9 kg (TR: 3.0, non-TR: 2.8). Three TR patients out of 10 underwent TV plasty in the Stage I Norwood operation. Another two TR patients underwent Norwood with hand made valved RV-PA conduit. In all the TR patients, we controlled pulmonary flow with clipping the RV-PA conduit. In all TR patients, TR was improved significantly after the stage I Norwood (P<0.01). Operative mortality was similar (TR: 0/10, non-TR: 1/19). The actuarial survival rates were 64.8% (TR) vs. 80.2% (non-TR) (5 years) (P=0.38: Logrank). The rate of final completion (Fontan: 12, biventricular repair: 3) was similar (TR 5/10, non-RT 10/19). Conclusions: The appropriate pulmonary flow control and surgical repair in Norwood operation improved the outcome in the operative survival of the patients with HLHS who had moderate/severe TR.
Department of Paediatric Heart Surgery, La Timone Hospital, Marseille, France Objectives: To highlight anatomic lesions and surgical procedures frequently complicated by secondary subaortic stenosis (SSS). Methods: A retrospective study of 4710 patients was performed between 1984 and 2005. The indication for inclusion in the study was the appearance or recurrence after an open or closed-heart operation of a fixed subaortic obstruction, requiring surgery. Fifty-two patients were included. Results: The mean age at initial surgery was 22 months (4 days to 47 years). SSS occurred after five main types of surgery: resection of discrete subaortic stenosis, atrioventricular septal defect repair, coarctation repair, LV-aorta rerouting and Fontan type operation. The mean delay of occurrence was 36 months (2 weeks to 19 years). Frequently associated initial anatomic conditions were left superior vena cava (18%), aortic bicuspidy (33%), coarctation (48%), mitral valve lesion (43%). Pre-operative lesions of the LVOT were present in 92% of cases, but obstructive only in 46%. The most frequent type of SSS was subaortic discrete or extended membrane with or without septal hypertrophy (n=40). Eight patients developed a second SSS 9 years after surgery (mean). One patient developed a third SSS. When compared with patients without SSS, significant risk factors to develop a SSS were low age at surgery (22 vs. 62 months, P<10–4) and preexisting coarctation of the aorta (48 vs. 5%, P<10–4). Conclusions: SSS is a multifactorial lesion depending on both the initial anatomic lesions and the type of surgery. Low age at initial surgery and coarctation of the aorta significantly increase the risk of SSS.
Tokyo Women's Medical University, Tokyo, Japan Objectives: Our strategy for PA with VSD and MAPCA is a staged approach; 1st complete unifocalisation (UF) with ‘unification’ of intrapulmonary arteries and 2nd Rastelli procedure. The purpose of this study is to assess the results of our approach. Methods: From 1982 to 2004, 113 consecutive patients with PA with VSD and MAPCA were treated with staged approach in our institute. We evaluated the risk factor of exclusion from Rastelli procedure or death in 3 years after Rastelli procedure in Logistic regression. Furthermore, we compared early group (patients underwent Rastelli procedure before 1995) and late group (after 1995). Results: Mean follow-up interval was 8.9±6.2 years (0.8 months to 23.3 years), and Kaplan-Meier estimated overall survival rate after 1st UF was 81.0%, 73.6%, and 69.4% in 5, 10, and 15 years, respectively. Survival rate in patients without central PA was significantly lower than in overall patients (60.0% and 51.4% in 5 and 10 years, P<0.05), and the risk factor for exclusion of Rastelli procedure or death in 3 years after Rastelli procedure was absent central PA (P<0.05). In late group, each age at UF (8.5 vs. 3.6 years, P<0.01) and Rastelli procedure (9.0 vs. 5.9 years, P<0.05) was significantly younger, and RV pressure after Rastelli procedure in late group was significantly lower than in early group (74 vs. 55 mmHg, P<0.01). Conclusions: Absent central PA was significant risk factor in this group. RV pressure after Rastelli procedure in late group with staged approach at younger age was improved, and this result may affect long-term outcomes.
Birmingham Children's Hospital, Birmingham, UK Objectives: High concentrations of potassium (K+) and lactate in irradiated red cells (IRC) transfused during cardiopulmonary bypass (CPB) may have detrimental effects on infants and neonates undergoing cardiac surgery. The effects of receiving washed and unwashed IRC from the CPB circuit on serum [K+] and [lactate] were compared. Methods: A control group (n=11) received unwashed IRC and the study group (n=11) received IRC washed in a cell saver (Dideco Electa) using 900 ml of 0.9% saline prior to pump priming. Potassium and lactate concentrations were compared before, during and after CPB. Results: Washing IRC significantly reduced donor blood [K+] from 20 to 0.8±0.1 mmol/l (P<0.001), and [lactate] from 13.7±0.5 to 5.0±0.3 mmol/l (P<0.001). The resulting prime had significantly lower [K+] and [lactate] than the unwashed group (K+ 2.6±0.1 vs. 8.1±0.4 mmol/l, P<0.001; Lactate 2.6±0.2 vs. 4.6±0.3 mmol/l, P<0.001). Peak [K+] in the unwashed group occurred 3 min after going on bypass (4.9±0.3 mmol/l) and during rewarming (4.9±0.4 mmol/l). These were significantly higher than the washed group (3.1±0.1, P<0.001 and 3.0±0.1 mmol/l, P<0.001). The [K+] was greater than 6.0 mmol/l for 4 out of these 11 unwashed patients compared with none of the washed group. Immediately post-bypass the washed group had significantly lower serum [K+] (3.2±0.1 vs. 4.2±0.2 mmol/l, P=0.002). There was no significant difference in [lactate] between groups during and after CPB. Conclusions: The washing of IRC reduces K+ and lactate loads and prevents hyperkalaemia during CPB. The washing of IRC should be considered in neonates and infants undergoing cardiac surgery for complex congenital heart disease.
Royal Hospital for Sick Children, Yorkhill Division, Glasgow, UK Objectives: Peri-operative myocardial injury is a major determinant of post-operative ventricular dysfunction following repair of congenital heart defects. However, changing loading conditions and right ventricular geometry makes functional assessment problematic. We explored the potential of tissue Doppler imaging (TDI) to quantify ventricular function, its relation to myocardial injury and post-operative outcomes. Methods: Twelve children, aged 4–35 months, undergoing corrective repair of congenital heart defects (AVSD, n=7, VSD n=3, ASD n=2) were studied. Troponin-I (cTnI) was measured at 1 and 15 h post-operatively. Simultaneous tissue Doppler and M-mode images were recorded for later off-line analysis. Systolic myocardial velocities, including isovolumetric acceleration and peak annular velocities, were measured in the left and right ventricles and correlated with intra-operative (aortic cross clamp and bypass times) and post-operative variables (inotrope score, ventilation time and ITU stay). Results: Post-operatively there was a significant reduction in RV peak systolic velocities (cm/s) in all patients (pre-op 7.94±3.29; post-op 2.37±0.86; P=0.001). Additionally a strong negative correlation existed between the RV velocities and both cTnI (r=–0.94) and ischaemic time (r=–0.96). By contrast, LV peak systolic velocities demonstrated a variable post-operative pattern and a weaker correlation with cTnI (r=–0.76) and ischaemic time (r=–0.71). Peak LV velocities did however, significantly correlate with post-operative outcomes including ventilation time (r=–0.71) and ITU stay (r=–0.88). Conclusions: This study identified a strong relationship between peri-operative myocardial injury and RV dysfunction as assessed by TDI. Furthermore, LV analysis may be useful in predicting post-operative outcomes.
Oregon Health Sciences University, Portland, USA Objectives: Deep hypothermic circulatory arrest (DHCA) is frequently used for neonates undergoing the Norwood procedure. These infants are severely cyanotic after separation from CPB. Because we have previously demonstrated cerebral autoregulation to be deficient following DHCA, we tested the hypothesis that post-operative cyanosis exacerbates histological brain injury following DHCA. Methods: Neonatal piglets were exposed to 2 h uninterrupted DHCA at 18 °C via aortoatrial CPB, and then supported in our laboratory intensive care, anaesthetised and ventilated with full invasive monitoring. Post-operative oxygenation was controlled to maintain arterial tensions either normoxaemic (NOR, n=5) or hypoxaemic (HYP, n=7) (PaO2 40–50 mmHg) for 24 h. After perfusion-fixing, brains were blindly scored for regional histological injury using light and FluoroJade(tm) fluorescent microscopy. Controls included ‘instrumented without CPB’ (SHAM, n=3)) and non-ischaemic controls (deep hypothermic full-flow CPB, with postCPB hypoxaemia (DHFF, n=3)). Results: Postoperative haemodynamic and acidbase parameters were indifferent. SHAM and DHFF animals were normal and indistinguishable. Normoxaemic animals (NOR) had injury score 7.25±4.5 or 6.25±5.8 by light and fluorescent microscopy. Of hypoxaemic group (HYP), 3 suffered irretrievable brain injury (loss of reflexes, severe cerebral oedema) precluding histological quantification. The remaining 4 had significantly greater ischaemic histological changes (14.5±1.5, P=0.03 and 14.25±2.5, P=0.04). The hippocampal dentate gyrus was consistently most vulnerable. Conclusions: Loss of cerebrovascular autoregulation following DHCA has serious implications for cyanotic staged palliation. Post-CPB cyanosis results in significant amplification of cerebral injury from DHCA. Such infants therefore represent a subset in which DHCA should preferentially be avoided. Techniques for augmenting oxygen delivery (ECMO) may instead protect against this mechanism of injury and warrant investigation.
024 - O LOCAL RECURRENCE MODEL OF MALIGNANT PLEURAL MESOTHELIOMA FOR INVESTIGATION OF INTRAPLEURAL ADJUVANT TREATMENT I. Opitz1, D. Lardinois1, S. Hillinger1, M. Welti1, P. Vogt2, S. Arni1, M. Cardell1, W. Weder1 1Division of Thoracic Surgery, University Hospital, Zurich, Switzerland; 2Division of Clinical Pathology, University Hospital, Zurich, Switzerland Objectives: Development of a standardized local recurrence model for malignant pleural mesothelioma in rats to study local adjuvant therapies. Methods: Recurrence model: A tumour cell suspension of 50 µl 1x106 of rat malignant mesothelioma cells was inoculated subpleurally. Six days later, the tumour nodule was measured and completely resected. Local recurrence at the resection site was assessed after 6 and 10 days. Results: Recurrence model: six days after tumour cell inoculation, all animals developed a tumour nodule at the injection site of a mean diameter of 5.1 mm (±0.8). At 10 days after complete resection, local and distant recurrences in the contralateral chest were found. At 6 days local recurrence only occurred. Local adjuvant treatment with cisplatin-sealant and taurolidine significantly reduced the mean tumour volume of local recurrence from 2200 mm3 in the control to 715 mm3 in the taurolidine to 55 mm3 in the cisplatin-sealant group (P=0.027). Conclusions: We were able to develop for the first time a local recurrence model for MPM in rats. Herewith a significant reduction of tumour growth after local treatment with slow-released cisplatin and taurolidine was demonstrated.
Medical University of Vienna, Vienna, Austria Objectives: Primary graft dysfunction (PGD) is a severe complication in lung transplantation. Therapeutic strategies are limited; and there exist no predictive markers for PGD. Vascular endothelial growth factor (VEGF) is the key regulator of vascular permeability, and its pulmonary tissue levels increase in lung graft oedema. This study sought to investigate whether pre-transplant VEGF serum concentrations could predict PGD. Methods: Pre-transplant VEGF serum concentrations were measured in 120 patients undergoing lung transplantation and in 12 controls by ELISA. The ischaemia time of the grafts and the donors’ PaO2/FiO2 ratios were comparable. PGD was diagnosed and scored from 0 to 3 by characteristic changes in chest radiographs and PaO2/FiO2 ratios according to the International Society for Heart and Lung Transplantation guidelines.
Results: PGD Grades 0–3 occurred in 22, 44, 22, and 12% of patients, respectively. Pre-operative VEGF serum concentrations were significantly higher in patients with PGD Grade 2 (760±508 pg/ml; P=0.008) and 3 (1248±915 pg/ml; P=0.001) vs. those with Grade 0 (367±274 pg/ml) and controls (380±205 pg/ml). VEGF serum concentrations significantly predicted PGD Grades 2 and 3 in receiver operating characteristic curve analysis (P<0.0001, AUC=0.743, CI=1.001–1.003). At a cut-off level of Conclusions: Pre-operative VEGF serum concentrations in patients awaiting lung transplantation could help identifying those at risk for PGD.
1University Federico Ii, Naples, Italy; 2Royal Brompton Hospital, London, UK; 3Monaldi Hospital, Naples, Italy Objectives: This study investigates the prognosis of patients with different extension surgical resection and with different location of N1 nodes. Survival rates were compared between two follow-up patient groups: 1st patient group treated by pneumonectomy with lymph node station involvement or metastatic spread to station 10 and/or 11 and/or direct hilum (fixed node group); 2nd patient group treated by lobectomy with limph node station involvement or metastatic spread 10 and/or 11 and/or hilum (mobile node group). Methods: Of 1146 patients operated, we retrospectively studied 86 follow-up (7.25%) consecutive patients with pN1 disease who underwent a major lung resection for NSCLC, at the Royal Brompton Hospital, from April 1992 to December 2004. Preoperative staging for metastatic disease was negative. No neo-adjuvant or post-operative therapy was given. Detached hilar and mediastinal systematic nodal dissection was performed in all cases. Survival rates were calculated by using the Kaplan-Meier life-table and survival curve comparison by using a long-rank test. Results: The pathology reports revealed 50 squamous-cell, 25 adenocarcinomas, and 11 large cell carcinomas. The overall 5-year and 10-year survival rate in the two groups with N1 disease was 54% (mobile group) and 24% (fixed node) respectively with a median of 66 months. No significant difference was found in the two groups but a better median survival rate in the group treated by lobectomy with mobile node related to the age, sex, pT status, type of lymph node spread. Conclusions: This study confirms the importance of staging lung cancer on TNM, lymphanodectomy and the presence of mobile or fixed node as new prognostic factor.
Uludag University School of Medicine, Bursa, Turkey Objectives: Mediastinoscopy is the most important tool for staging of lung cancer that is performed in almost every lung cancer case with Stage II-IIIb lung cancer. The aim of this study was to compare fine needle aspiration biopsy of mediastinal lymph nodes with tissue biopsy performed during mediastinoscopy. Methods: Sixty-one patients with lung cancer and undergoing staging mediastinoscopy were prospectively enrolled into the study. Tissue biopsies and fine needle aspiration biopsies (FNAB) have been obtained from the same lymph node and sent for a pathologic examination. At least two FNABs were performed from the same lymph node. Tissue biopsies were investigated with frozen section as well as paraffin sections. Tissue biopsies were stained with haematoxylin-eosin (H&E) and fine needle aspiration biopsies with H&E and Giemsa. All specimens were investigated by two different histopathologist. Results: All but three patients were men (3/61, 5%) with a mean age of 56.4 (37–78) years, there was no complication related to both method. Although there were 33 benign reactive hyperplasia and 28 lymph node metastases in tissue biopsies there were 27 benign reactive hyperplasia and 34 lymph node metastases in fine needle aspiration biopsies. Although Classic biopsy revealed four further results when compared to FNAB, FNAB reveals nine further results when compared to classic biopsy. The difference was statistically insignificant (Pearson Chi-Square test P=0.277). Conclusions: Fine needle aspiration is a safe, reliable and effective method when compared to tissue biopsy during mediastinoscopy. It may also further reduce morbidity and give better evaluation of the lymph nodes during mediastinoscopy.
1Marmara University Faculty of Medicine, Department of Thoracic Surgery, Istanbul, Turkey; 2Istanbul University Faculty of Veterinary Medicine, Istanbul, Turkey; 3Marmara University Faculty of Medicine, Department of Pathology, Istanbul, Turkey Objectives: LigaSure (Valleylab, Tyco Healthcare, Boulder, CO) is a novel instrument for vessel sealing which uses heat energy to denature collagen and elastin. We investigated the safety of LigaSure in pulmonary arteries (PA) and veins (PV). Methods: Twelve sheep were endotracheally intubated. Six underwent right lower lobectomy (Group 1) and 6 upper (Group 2). PAs and PVs in both groups were divided using LigaSure. Diameters of vessels were measured. Following vascular division ephedrine was injected to increase PAP in Group 1. In Group 2, animals were followed and euthanized at 7 days. Immediate and 7 day samples were obtained from vessel stumps. Conventional histology was performed. Results: Mean diameter of PAs (n=9) in Group 1 was 8.3 mm (3–11) and of PVs (n=8) was 10.4 mm (4–15). Mean PAP increased from 18 (27/9) to 27 (45/18) mmHg after ephedrine injection. Dehiscence occurred in 2/6 of PAs and 3/6 of PVs larger than 9 mm. Mean diameter of PAs (n=8) divided in Group 2 was 5.7 mm (3–7) and of PVs (n=9) 4.6 mm (4–6). No early or late (7 days) dehiscence was seen in Group 2. No dehiscence was observed in vessels less than 7 mm in diameter. Histology of intraoperative samples showed thermal injury. 7 day samples showed necrosis, thrombus formation without inflammation or granulation tissue. Conclusions: LigaSure achieves perfect sealing in pulmonary vessels less than 7 mm in diameter in sheep intra- and postoperatively following a pressure challenge. It can safely be used in segmental branches of PAs and PVs during open or thoracoscopic surgery.
1Seoul National University Hospital, Seoul, Korea (South); 2Seoul National University Bundang Hospital, Seong-Nam, Korea (South) Objectives: The aim of this study is to identify the impact of extent of lymphadenectomy on the overall survival in oesophageal cancer. Methods: Between January 1995 and December 2003, 239 patients who were operated on due to oesophageal cancer were included in this study. The inclusion criteria were stage I, II, and III oesophageal cancer patients who underwent curative resection without neoadjuvant chemotherapy or chemoradiation. For the analysis of the extent of lymphadenectomy, lymph node stations were classified into 3 regions including upper thoracic, paraesophageal, and abdominal lymph node groups. Lymphadenectomy of 1 region was defined as Group 1, 2 regions as Group 2, and 3 regions as Group 3. Results: The predominant cell type was squamous cell carcinoma (97.1%) and the pathologic stages were stage I in 59 (24.7%), IIa in 70 (29.3%), IIb in 28 (11.7%), and III in 82 (34.3%). There were 69 patients (28.9%) in Group 1, 101 (42.3%) in Group 2, and 60 (25.1%) in Group 3. The 5-year survival of overall patients in Group 1, 2, and 3 was 23.1%, 36.6%, and 55.2% (P=0.02). The 5-year survival of N0 group was 30.1%, 55.3%, and 75.6% in Groups 1, 2, and 3 (P=0.008). The 5-year survival of N1 group was 10.8%, 18.7%, and 36.9% in Groups 1, 2, and 3 (P=0.052). Conclusions: The wider extent of lymphadenectomy in oesophageal cancer showed improved long-term survival than limited lymphadenectomy and especially N0 patients could benefit from the wide extent of lymphadenectomy in this study.
1Seoul National University Hospital, Seoul, Korea (South); 2Seoul National University Bundang Hospital, Seong-Nam, Korea (South) Objectives: The aim of this study is to identify the role of surgical resection in malignant mediastinal neurogenic tumour in children. Methods: Between 1986 and 2004, 38 consecutive children who underwent surgical resection of malignant mediastinal neurogenic tumour were included in this study. The cell types of tumours were neuroblastoma in 23 patients (60.5%), ganglioneuroblastoma in 14 (36.8%), and malignant neuroepithelioma in 1 (2.6%). Surgery was performed for the purpose of curative resection in localized tumours and salvage resection of residual mediastinal mass after chemotherapy in stage IV tumours. Of 16 patients (42.1%) who underwent salvage resection, there were 14 neuroblastomas and 2 ganglioneuroblastomas. Results: Mean age of patients was 3.4±3.0 years (1 month–13 years) and 26 patients (68.4%) were symptomatic at presentation. Adjacent structure invasion was found in 8 patients (21.1%), which was invasion of chest wall in 4, atrium and vena cava in 2, lung in 1, and chest wall and lung in 1. Complete gross resection was possible in 31 patients (81.6%) and there was no surgical mortality. Surgical morbidity occurred in 9 patients (23.7%) and Horner's syndrome was the most frequent complication (n=7). The 5-year survival was 89.3% for localized tumour and 39.6% for stage IV tumour (P=0.001). The significant risk factors for long-term survival were adjacent structure invasion (P=0.004) and stage IV tumour (P=0.032) in multivariate Cox regression analysis. Conclusions: Surgical resection of localized malignant mediastinal neurogenic tumour in children showed good long-term survival and salvage operation after chemotherapy also showed acceptable long-term survival.
Ondokuz Mayis University School of Medicine, Samsun, Turkey Objectives: In clinical practice of the thoracic surgery, after lung resection, the thoracic cavity may be filled partially or completely by the remaining pulmonary tissue. However, we have not been able to find a study evaluating quantitatively this volumetric change of thoracic content using high resolution computed tomography (HRCT). We aimed to evaluate quantitatively the volume changes of lungs using HRCT in the preoperative and postoperative period. Methods: In this study, we used HRCT on 17 patients with lung cancer taken preoperatively and one month later the resection operation. All the patients were male and their ages, weights and heights were 58.7 (40–76) years, 72.41 (46–80) kg, 1.73 (1.56–1.90) m, respectively. The volume and volume fraction of the lung were estimated by means of applying the point counting grids over the preoperative and postoperative HRCT. Total volumes of the pulmonary tissues were 6.58 and 4.58 litres in preoperative and postoperative periods, respectively. Results: While 30.41% pulmonary tissue was resected, the pulmonary tissue was diminished volumetrically in 22.35%. Volumetric analyses showed that the remaining tissues increased their volume in 8.06% to fill the thoracic cavity. Conclusions: Our results showed that the volume and volume fraction of the total pulmonary tissues could be evaluated on HRCT using the proposed method. The method could provide information to predict the postoperative progress before the resection.
033 - O FONTAN COMPLETION WITHOUT SURGERY A. Sallehuddin, F. Fadley, M. Barakati, M. Fayyadh, A. Mesned, Z. Halees King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia Objectives: To describe the outcome of a combined surgical-interventional technique for the creation of total cavo-pulmonary connection. Methods: During bidirectional Glenn, an intra-atrial lateral tunnel was created and fenestrated with a 10—14-mm hole. The cardiac end of SVC was patched to establish bidirectional physiology. During interventional completion, this patch was perforated using radio-frequency energy and stented. The fenestration was closed with a device. Paired t-test was used to compare data before and after Fontan. Results: From June 2003 to February 2006, 16 patients (9 boys and 7 girls, mean age 12 months) underwent the surgical procedure described. Mean bypass time was 137 min and mean ischemic time 77 min. There were no deaths. One patient with bilateral SVC required takedown due to recurrent effusions. 10 months later, 9 patients underwent completion (mean age 20 months, mean weight 10.6 kg). All except one fenestration was closed with a device. Stents were dilated to 14.4 mm average. Mean fluoroscopy time was 41 min. Oxygen saturation increased 85–94% (P=0.001). Pulmonary artery pressures remained normal (16 before and 19 mmHg after, P=0.12). None required mechanical ventilation. None developed effusions. All were discharged from hospital within 6 days. Twenty-two months after Fontan, all were well. Echocardiography revealed no gradients across the stents. Two patients had minor leaks across the fenestration. One underwent further stent dilatation 1 year later. Conclusions: Fontan without surgery is suitable in single ventricles with lower mortality and morbidity, avoids multiple surgical interventions while maintaining the staged approach and allows for successive dilatations.
Department of Cardiothoracic Surgery and Anaesthesiology, Örebro, Sweden Objectives: Conventional harvesting of the saphenous vein in coronary artery bypass surgery produces vessel damage that contributes to graft failure. A novel ‘no touch’ technique provides a higher short and long term patency rate. Methods: This randomised longitudinal trial compares the graft patency of two patient groups undergoing coronary artery bypass surgery. Conventional (C): 52 patients had their veins stripped, distended and stored in saline solution. No-touch (NT): 52 patients had veins removed with surrounding tissue, not distended and stored in heparinised blood. Angiographic assessment was performed at mean time 18 months after the operation in 46 patients in Group C and 45 patients in Group NT and repeated at mean time 8.5 years in 37 patients from both groups. Results: The distribution of the grafts to the recipient coronary arteries regarding their size and quality was similar in both groups. The angiographic assessment at 18 months postoperatively showed that 89% Group C vs. 95% Group NT grafts were patent. Repeated angiography at 8.5 years showed a patency rate for the C group of 76% and 90% for the NT group, P=0.01. The multivariate analysis showed that the most important surgical factors for graft patency were the technique of harvesting (P=0.007) for the NT vs. the C technique and the vein quality before implantation (P=0.007) for veins that were of good quality. By comparison the patency of the mammary artery grafts was 90%. Conclusions: Harvesting the saphenous vein with surrounding tissue provides high short and long term patency rate comparable to the left internal mammary artery.
1Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland; 2Department of Pathology, Jagiellonian University, Krakow, Poland; 3Department of Radiology, Jagiellonian University, Krakow, Poland Objectives: To compare the diagnostic yield of standard mediastinoscopy and transcervical extended mediastinal lymphadenectomy (TEMLA) in detecting metastatic mediastinal lymph nodes in NSCLC patients. Methods: Prospective, randomised, single-blind clinical study. Results: 41 NSCLC patients were randomised: 21 to the TEMLA group and 20 to the mediastinoscopy group. Both groups were comparable regarding patient's age, gender, cTNM, histology and location of the tumour. The TEMLA revealed mediastinal metastases in 7 patients, and mediastinoscopy in 3. In patients with negative nodes, thoracotomy with appropriate pulmonary resection and mediastinal dissection was performed: in 13/14 patients from TEMLA group and in 15/17 patients from mediastinoscopy group. Unsuspected metastatic N2 nodes were discovered in operative specimen after thoracotomy in 5/15 patients from mediastinoscopy group vs. 0/13 patients in TEMLA group (P=0.019); this significant difference was the reason of terminating the randomisation before reaching the initially planned number of 100 patients. The sensitivity of mediastinoscopy was 37.5% and its negative predictive value was 66.7%, comparing with 100% and 100% in the TEMLA group. Conclusions: The sensitivity and the NPV of the TEMLA in detecting mediastinal metastases in NSCLC patients are significantly greater than that of cervical mediastinoscopy.
Marie Lannelongue Hospital, Le Plessis-Robinson, France Objectives: To identify anatomical and surgical factors influencing the early and late outcome in patients with complex coronary artery anatomy undergoing arterial switch operation (ASO). Methods: Since 1991, 1195 consecutive patients underwent ASO. Forty-five (3.8%, 70% CL: 3.2-4.4%) presented with inter-arterial (type C, Yacoub) coronary artery course. Both coronary arteries were arising from sinus #2 in 33 and from sinus #1 in one. In the remaining 11, at least one of coronary ostia was located above the posterior aortic valve commissure. Intramural course was observed in 27, 5 associated with an ostial stenosis. Sixteen (35%) had associated VSD. The operative technique consisted in detachment of the posterior commissure and excision of the coronary ostia as a single disc in all. The latter was relocated with use of a PTFE hood in 3. In 42, following division into two cuffs, a uniform transfer technique was employed. Unroofing of the intramural segment was performed in 12. Results: There were 7 hospital deaths (15.5%, 70% CL: 9–23%), 6 due to coronary malperfusion. All were associated with initial intramural course. Follow-up was complete in all survivors. Three patients (6.6%, 70% CL: 2–13%) died second month after discharge because of acute myocardial ischaemia. Four patients required left coronary artery bypass procedure 4, 36, 60 days and 9 years after repair with good recovery. Conclusions: ASO in patients with inter-arterial/intramural coronary course remains associated with frequent coronary ischemic complications. Coronary artery bypass procedure for postoperative myocardial ischaemia appears to be life saving.
Erasmus University Medical Centre, Rotterdam, Netherlands Objectives: Whether allografts are the biological valve of choice for AVR in nonelderly patients remains a topic of debate. In this light we analysed our ongoing prospective allograft AVR cohort and compared allograft durability with other biological aortic valve substitutes. Methods: Between April 1987 and October 2005, 336 patients underwent 346 allograft AVRs (95 subcoronary, 251 root replacement). Patient and perioperative characteristics, cumulative survival, freedom from reoperation and valve-related events were analysed. Using microsimulation, for adult patients age-matched actual freedom from allograft reoperation was compared to porcine and pericardial bioprostheses. Results: Mean age was 45 years (range 1 month to 83 years), 72% were males. Etiology was mainly endocarditis 32% (active 22%), congenital 31%, degenerative 9%, and aneurysm/dissection 12%. 27% underwent prior cardiac surgery. Hospital mortality was 5.5% (n=19). During follow-up (mean 7.4 years, max 18.5 years, 98% complete) 54 patients died, there were 57 valve-related reoperations (3 early technical, 12 non-structural, 38 structural valve deterioration (SVD), 4 endocarditis), 5 CVAs, 1 fatal bleeding, 8 endocarditis. Twelve-year cumulative survival was 71% (SE 3), freedom from reoperation for SVD 77% (SE 4); younger patient age was associated with increased SVD rates. Actual risk of allograft reoperation was comparable to porcine and pericardial bioprostheses in a simulated population. Conclusions: The use of allografts for AVR is associated with low occurrence rates of most valve-related events but over time the risk of SVD increases, comparable to stented xenografts. It remains in our institute the preferred valve substitute only for patients with active aortic root endocarditis and for patients in whom anticoagulation is to be avoided.
Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria Objectives: Extracorporeal membrane oxygenation (ECMO) has a broad spectrum of potential applications in the setting of lung-transplantation (LuTX). Besides oxygenation support reduction of pulmonary bloodflow via veno-arterial cannulation can be achieved. Methods: All 306 primary LuTX (247 DLuTX, 59 SLuTX) from January 2001 to December 2005 were retrospectively analysed with regard to the use of ECMO. ECMO was used to bridge patients on the waiting list, intraoperatively instead of cardiopulmonary bypass (CPB) if haemodynamic or respiratory support was required and postoperatively as planned prolonged support as well as in cases of primary graft-failure or severe reperfusion-oedema. Results of all patients requiring ECMO were compared to those without ECMO during the observation-period. Results: During the observation-period 143 patients did not require any extracorporeal support. ECMO was used in 146 patients (77 intraoperative, 52 intra- and postoperative, 15 postoperative, 2 pre-, intra- and postoperative). Cannulation-site was central in 49 patients, central+femoro-femoral in 27 and femoro-femoral in 70 patients. CPB only was used in 17 patients mainly with concomitant cardiac defects. As expected median time to extubation was longer in the ECMO-group (4 days vs. 2 days, P<0.01), median ICU-stay was 9 vs. 6 days (P<0.01) and median hospital-stay 25 days in both groups. ECMO-related vascular complications were observed in 7 patients. 3-months-survival-rates were 95.33% (no ECMO), 85.86% (intraoperative±postoperative ECMO) and 53.33% (postoperative ECMO). One-year survival rates were 93.03%, 73.77% and 45.71% (all: P<0.01). Conclusions: ECMO is a valuable tool in LutX providing the potential to bridge patients to transplantation, to replace CPB and to overcome severe postoperative complications. Favourable survival-rates can be achieved despite the fact that ECMO is used in the most complex patient population undergoing LuTX as well as to overcome already established severe complications.
039 - O IS VALVE FUNCTION AND LIFE QUALITY FOLLOWING IMPLANTATION OF A MECHANICAL COMPOSITE SUPERIOR TO THE COMBINATION OF ROSS PROCEDURE COMBINED WITH REPLACEMENT OF ASCENDING AORTA? P. Akhyari, T. Kofidis, C. Bara, N. Khaladj, A. Haverich, U. Klima Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany Objectives: The Ross procedure is occasionally favoured in young adults. However, in patients undergoing simultaneous replacement of the ascending aorta the implantation of a mechanical conduit may be a competing option. Methods: Twenty patients with a mechanical composite graft (A) and 18 patients with a pulmonary autograft and ascending aortic replacement (B) were compared postoperatively. The cumulative follow-up period was 56.9 respectively, 78.9 patient-years. Preoperative NYHA class was 2.0±0.6 (B) and 1.7±0.8 (A), mean bypass time 181.3 min (B) vs. 116.6 min (A). Echocardiographic studies were all conducted by the same examiner. The Short Form Health Survey (SF36) was used to assess life quality (LQ). Results: There was one re-operation (B), seven autograft patients presented with mild regurgitation, mean gradient across the autograft averaged 3.1±1.9 mmHg. None of the composite prosthesis showed paravalvular leakage. LV mass and global LV function were similar between groups (mean EF 65.5% in B vs. 61.6±10.4% in A). Four allograft patients (B) had mild valve regurgitation, two had mild to moderate, one showed moderate pressure gradients (14.4 mmHg). Patients in the composite group had significantly higher SF36 scores indicating superior life quality. No long-term postoperative bleeding was noted. Conclusions: The examined patients exhibit comparable morbidity. Despite pre-OP diminished LV function in the composite group (A) similar follow up values and a higher LQ outcome favour the implantation of mechanical conduits and demand further evaluation of these data in larger patient cohorts.
Central Hospital, Izmir, Turkey Objectives: Positive results of edge-to-edge technique encourage us to analyse whether association of this method to De Vega annuloplasty would result in less residual tricuspid insufficiency in patients with massive regurgitation. Methods: Thirty-nine patients with TR > 3 consisted study population and were randomised in a double blind fashion to undergo modified De Vega alone (Group D, 20 patients) or associated with edge to edge repair (Group E, 19 patients). All patients had preoperative and early postoperative (before discharge) echocardiography. The tricuspid regurgitation, diameter of tricuspid valve annulus, pulmonary artery pressure and right ventricular ejection fraction were recorded. Follow-up was completed in all patients. Results: Early postoperative echocardiography indicated less residual TR in Group E (mean TR; 1.2+0.2 vs. 0.6+0.1 P: 0.0243) while other parameters (diameter of TVA, TTV gradient, PAP and RVEF) were comparable. The mean follow-up period was 24.2+4.4 months. Mid-term postoperative (mean 20+2.8 months) mean TR was 1.9+0.8.vs 1.0+0.4 (P: 0.0384) indicated less redevelopment of TR in Group E. Additionally TVA redilatation was found more prominent in Group D. One patient (% 5.2) in Group D underwent operation for recurred TR. Most of the patients enjoyed symptomatic relieves in both groups however less patients were found at NYHA grade 3 or 4 in Group E. Conclusions: Our results suggested that association edge-to edge technique to De Vega annuloplasty in patients with severe TR has resulted in reduced residual TR and less incidence of recurrence of TR and TVA dilatation.
Department of Thoracic and Cardiovascular Surgery, University Hospital, Frankfurt, Germany Objectives: The pulmonary autograft, or Ross procedures has theoretical benefits over other aortic valve replacements. The haemodynamic performance during stress test of the pulmonary autograft and the aortic homograft have not been well defined during long term follow-up. Methods: Forty patients after Ross procedures underwent exercise echocardiography with assessment of left ventricular function, dimension and mass, including Doppler gradients across the pulmonary and aortic valves. Mean follow-up period was 66 months. Results: The mean exercise capacity was 145 Watt, the mean duration of stress testing was 8 min. Mean aortic valve gradient at rest was 8.5 mmHg, the velocity at rest was 145 cm/s. Mean pulmonary valve gradient at rest was 4.6 mmHg, the velocity at rest was 85 cm/s. Mean aortic valve gradient during maximum exercise was 29 mmHg, the velocity was 185 cm/s. Mean pulmonary valve gradient during maximum exercise was 12 mmHg, the velocity was 155 cm/s. No increase of aortic or pulmonary regurgitation was seen. In two patients, a significant increase of pulmonary valves gradients was assessed. Conclusions: The pulmonary autograft exhibits haemodynamic characteristics similar to the native aortic valve during enhanced cardiac output. No significant increase of Doppler gradients was seen across the pulmonary autograft except in two patients with an autograft stenosis of 60%. The Ross procedures have several advantages, but this is counterbalanced by the deterioration of the pulmonary homograft in up to 20%. Further long-term studies are necessary to evaluate the incidence of autograft stenosis and long-term haemodynamics parameters like coronary blood flow.
Cliniques Universitaires Saint Luc, Brussels, Belgium Objectives: In mitral valve (MV) infective endocarditis, timing of surgery and management of complex valves lesions remain two controversial topics. Early surgical approach and use of different techniques of repair characterise our last 12-years experience reported in this study. Methods: Between 1992 and 2004, 81 patients were operated during active phase of MV endocarditis, 63 of them (78%) underwent MV repair and represent the cohort of this study. Median time between diagnosis and surgery was 10 days. A variety of surgical techniques were used to restore MV complex, including biological patches of pericardium, autograft or homograft implanted as leaflets substitutes in 59% of the patients. Prosthetic rings were used in 44% of the patients. Results: Operative mortality was 17.5% and only 2.4% considering patients in preoperative NYHA class I and II. Mean follow-up was 60±37 months. During this period, 5 late deaths occurred, 2 were cardiac-related. Overall survival rates were 73±12% and 69±13% at 5 and 10 years. In hospital survivors, freedom from cardiac death was 93±8% at 10 years. Freedom from MV reoperation was 89±10% and 72±24% at 5 and 10 years. Only one endocarditis recurred after 4 months. In 4 patients MV was successfully re-repair. Ten years freedom from MV replacement and from endocarditis recurrence was 95±5% and 98±1%, respectively. At follow-up, all patients were in NYHA class I or II with 89% of them having a mitral regurgitation grade 1 or less. Conclusions: The present study demonstrates the feasibility, safety and durability of MV repair early in the course of active endocarditis.
Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada Objectives: To examine the outcomes of surgery for active infective endocarditis with paravalvular abscess. Methods: One hundred and fifty consecutive patients were operated. Their mean age was 51±17 years and 102 were men. The abscess was located in the aortic annulus in 62 patients, mitral annulus in 25, aortic and mitral annuli in 55, aortic and tricuspid annuli in 6, and aortic, tricuspid and pulmonary in 2. The infected valve was prosthetic in 72 patients. The approach of radical resection of all infected tissues and reconstruction with patches was employed in all patients. Aortic valve homograft was used in only 13/128 who had aortic valve replacement. The mean follow up was 6.0±5.5 years and was 99% complete. Results: There were 23 operative and 39 late deaths. Preoperative shock (odds ratio, OR=4.5), prosthetic valve (OR=2.1), and renal failure (OR=2) were independent predictors of operative death. Kaplan-Meier method was used to estimate the following outcomes: Survival was 81±2%, 72±4%, 58±5% and 39±6% at 1, 5, 10 and 15 years, respectively. Freedom from reoperation was 100%, 97±2%, 88±4% and 74±9% at 1, 5, 10 and 15 years, respectively. Freedom from endocarditis was 97±2%, 89±3%, 84±4% and 84±4% at 1, 5, 10 and 15 years, respectively. Freedom from patch and/or valve dehiscence was 99±1%, 98±1%, 96±2% and 92±4% at 1, 5, 10 and 15 years, respectively. Conclusions: Radical resection of paravalvular abscess results in cure of the infection in most patients regardless of the type of valve implanted. This approach is associated with high operative mortality but the long-term results are excellent.
Deutsches Herzzentrum Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany Objectives: Most patients with RSE can be treated medically, with surgery necessary in only few cases. We reviewed our 20-year surgical results in active, infective RSE. Methods: Between March 1986 and March 2006, 78 patients with tricuspid valve endocarditis (TVE, n=53 males, median age 36 years, range 2–89 years) and 13 with pulmonary valve endocarditis (PVE, n=7 males, median age 50 years, range 7–77 years) had to be operated on due to persisting fever, intractable right heart failure, uncontrollable sepsis, or large vegetations. There were 79 cases of native and 12 of prosthetic valve endocarditis. We performed 32 TV replacements (n=23 biological), 46 TV reconstructions including leaflet resection, annular plication and annuloplasty, pericardial patch leaflet and annular reconstruction, 11 PV replacements (n=4 homograft, n=7 Shelhigh) and 2 vegetectomies of PV. Univariate and multivariate analysis and Kaplan-Meier survival curves were applied. Results: The overall 1-, 5- and 15-year survival rate was 77.0±4.0%, 61.7±5.8% and 56.6±6.4%, respectively. There was a tendency towards better survival following TV reconstruction. Eight patients (8.6%, n=6 after TV reconstruction) developed recurrent infection leading to reoperation. Predictors of early mortality were renal insufficiency, emergency operation and age. Predictors for late outcome were reoperation and recurrent prosthetic valve endocarditis. Conclusions: Our surgical strategy for RSE is based on 3 principles: 1. Debridement of the infected area or vegetectomy. 2. Valve repair whenever possible, avoiding artificial material. 3. If valve replacement is unavoidable, use of a biological substitute without any artificial material that might become infected. Following this strategies clinical results achieved are very good.
Cardiovascular Surgery and Infectious Diseases, Hospital Clinic, University of Barcelona, Barcelona, Spain Objectives: There is an important role for accurate risk prediction in cardiac surgery. Prediction models are useful in decision-making and quality assurance. Patients with infective endocarditis (IE) are a particularly high-risk of morbidity and mortality. The aim was to assess the performance of the EuroSCORE model in acute IE. Methods: The additive and logistic EuroSCORE models were applied to all patients undergoing surgery for acute IE (Duke Criteria) between January 1995 and March 2006 within our institutional medical-surgical database. Observed and predicted mortalities were compared. Model discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. Results: 177 patients undergoing 188 operations with complete data were analysed. Observed mortality was 29.25%. For the entire cohort the mean additive score was 10.11 (additive predicted mortality of 14.17%). The mean logistic predicted mortality was 24.62%. Discriminative power was good for the additive model. Area under ROC curve were 0.810 (additive) and 0.529 (logistic) for the entire cohort, 0.761 and 0.510 for the aortic position, 0.940 and 0.411 for the mitral position, 0.797 and 0.471 for the native valve, 0.759 and 0.659 for the prosthetic valves and 0.813 and 0.509 for the Gram+ microorganisms respectively. Conclusions: Even though this initial sample size may be small, the additive EuroSCORE adequately stratifies risk in IE and logistic does not. Logistic EuroSCORE needs calibration in IE as this is a special group of very high-risk patients (additive >10).
046 - I IMPLANTATION OF A NEW SENSOR DURING CARDIAC SURGICAL PROCEDURES: AN INNOVATIVE APPROACH FOR LIFE-LONG BLOOD PRESSURE MONITORING C. Heilmann1, E. Just2, K. Förster1, P. Bingger2, S. Kressin2, P. Woias2, F. Beyersdorf1 1University Hospital Freiburg, Department of Cardiovascular Surgery, Freiburg, Germany; 2Albert Ludwigs University Freiburg, Department of Microsystems Engineering, Freiburg, Germany Objectives: Non-invasive, continuous, long-term blood-pressure monitoring in high-risk cardiovascular patients and during axial blood flow (e.g., LVAD) is currently not possible. Therefore, an implantable blood pressure sensor (patent-pending) was created. Methods: The sensor consists of conductive silicone (65 µm x 1 mm) spin-coated with bio-compatible silicone (150 µm thick), and is mechanically and electrically closed by a customary vessel-clip. The blood pressure inside a vessel corresponds to its dilation. This dilation expands the strip and causes changes in the electrical resistance, which is registered. The cuff's elasticity fits that of human blood vessels with Ø > 3 mm. In-vitro tests were done on artificial silicone arteries with a pump and a magnetic valve generating pulsating flow. In vivo, strips were implanted at the carotid artery in rabbits (n=6) to test the bio-compatibility. After 3 or 6 weeks (n=3 each), the rings were evaluated in situ, explanted, and subjected to haematoxylin-eosin, Elastica-van-Gieson, and anti-CD31 (endothelial cells) staining. Results: The pressure curves registered by the strain-sensor correlated closely with the reference curves. Linear measuring behaviour was registered up to 750 mmHg. In vivo, the strip was tolerated well by all animals. At explanation, all rings could be shifted against the vessel wall. A thin capsule without endothelium had formed around the strip. There was no inflammation, vessel constriction, or elastic fibres. Conclusions: Our implantable strain-sensor reliably records experimental blood pressure curves and is bio-compatible. The device is undergoing further development. It will be implanted in high-risk cardiovascular patients during the surgical procedure already necessary to treat the underlying disease.
Experimental Cardiac Surgery, Leuven, Belgium Objectives: We assessed the haemodynamic performance and calcification potential of a new pericardial valve (Trilogy, Arbor Surgical Technologies) compared to the CE-Perimount valve in a sheep model of mitral valve replacement. The Trilogy valve has a trilobal geometry and independent leaflet suspension design which reduce tissue stress and improve leaflet kinematics. Methods: Fifteen sheep received either a Trilogy (n=9) or a CE-Perimount (n=6) valve in mitral position. Haemodynamic measurements were performed at 1 week, 3 months and 5 months using transthoracic echocardiography by an independent cardiologist, blinded to the valve type inserted. After 5 months implantation, valves were explanted and examined by X-ray, histology and by calcium content measurement (atomic absorption spectrometry). Results: The Trilogy valves had significantly lower peak velocities, peak gradients, and mean gradients compared to the Perimount valves. The 21-mm Trilogy valves had similar deceleration times and effective orifice areas compared to the 23- and 25-mm Perimount valves. Commissural regions in the Perimount were clearly more calcified on X-ray analysis, which was confirmed by the calcium content of the commissural samples: 1.56±1.42 µg/mg dry wt in the Trilogy, compared to 12.10±14.84 in the Perimount. Trilogy valve leaflets had an overall calcium content of 1.33±0.68 compared to 7.14±8.52 in the Perimount. Conclusions: In our sheep model of mitral valve replacement, the Trilogy valve is superior to the CE-Perimount in early haemodynamics and calcification potential.
Herzzentrum Leipzig, Leipzig, Germany Objectives: Controlled hypoperfusion during hypothermia is required for the correction of complex congenital cardiac defects. Aim of this study was to evaluate the potential for cerebral protection by using selective cerebral perfusion (SCP). Methods: Piglets (n=15, 7–10 kg, age 3–4 weeks) received extracorporeal circulation (ECC) at 25°C for 90 min of cardioplegic cardiac arrest. SCP was performed at different flow rates via the right common carotid artery and all collateral vessels were snared. Regular brain perfusion (1 ml/g/min), moderate hypoperfusion (0.5 ml/g/min) and extensive hypoperfusion (0.25 ml/g/min) were evaluated. Clinical parameters and tissue oxygenation index (TOI) were registered online until 3 h of reperfusion. Potential brain ischaemia was quantified using HE staining and immunohistological analyses for heat shock protein (HSP) 70 and apoptosis inducing factor (AIF) on sections of the hippocampus. Results: Intracranial pressure remained stable throughout the study. Haemodynamic parameters, blood gas and lactate measurements were within the normal range until the end of the study. TOI was moderately reduced and HSP70 immunopositivity significantly increased after extensive hypoperfusion. AIF immunopositive nuclei were present in 23.5% after regular perfusion, in 37.6% after moderate and in 49.5% after extensive hypoperfusion. Conclusions: Unilateral selective cerebral perfusion is a safe concept when using regular perfusion as well as moderate hypoperfusion. Extensive hypoperfusion (25% of regular blood flow) is associated with increased initiation of apoptosis indicating cerebral ischemia. The noninvasively obtained tissue oxygenation index is a useful clinical parameter to assess cerebral protection by SCP during complex cardiac surgery.
1Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany; 2Institute of Experimental Medicine, University of Cologne, Cologne, Germany; 3Institute of Anatomy, University of Cologne, Cologne, Germany Objectives: To investigate cerebral endothelial changes during DHCA/reperfusion in mini-piglets. Methods: Three groups of 8 mini-piglets each were subjected to 40-min cooling, 60-min DHCA at 15 °C, 40-min rewarming on CPB followed by 30-min normothermic bypass, Group 1 underwent DHCA, Group 2 DHCA plus premedication with Eptifibatide, Group 3 DHCA plus ASCP (20 ml/kg/min), a sham-group served as control. The brain was then removed after prefixation, dissected in standardised fashion and postfixated. Morphological investigation of hippocampal and cortical tissue, which were processed for light and electron microscopic analysis, was performed. A histological mapping of different brain areas, investigating the endothelial capillary integrity and the surrounding brain tissue, was performed using a histological score system. Score 0, 1, 2 and 3 describe the increasing severity of endothelial disintegration and perivascular oedema formation. Results: Severe damage appeared in Group 1, most of the capillaries presenting score 3 (32%) and 2 (29%). In Group 2 and 3, most of the vessel changes showed score 1 (40% and 45% had score 1; 28% and 26% had score 2, respectively). The sham-group showed only score 0 and 1 (60% and 40% respectively). There was no significant difference between hippocampus and cortex. The loss of the endothelial integrity in group1 is supported by the markedly increased number of macrophages localised in the brain tissue outside the vessels. Conclusions: Morphological brain mapping showed the efficacy of ASCP and Eptifibatide in protecting the endothelial lining of cerebral capillaries and thus reducing brain injuries in the cortex as well as in the hippocampus during DHCA/reperfusion.
1Department of Cardiothoracic Surgery, Tel Aviv Medical Centre, Tel Aviv, Israel; 2Department of Mechanical and Aerospace Engineering, Raleigh, NC, USA; 3Division of Cardiothoracic Surgery, University of Chicago Hospitals, Chicago, IL, USA Objectives: Acute and chronic pain after median sternotomy is common and often underestimated. The mechanical retractors used for the median sternotomy exert significant forces on the skeletal cage. Our hypothesis is that instrumented retractors can be developed to enable real-time monitoring and control of retraction forces. This may provide equivalent exposure with significantly reduced forces and tissue damage, and thus less post-operative pain. Methods: A novel instrumented retractor was designed and fabricated to enable real-time force monitoring during surgical retraction. Sixteen mature sheep underwent median sternotomy. Eight median sternotomies were retracted at a standard ‘clinical pace’ of 7.25±0.97 min to 7.5 cm without real-time monitoring of retraction forces. The other eight median sternotomies were retracted to the same exposure using real-time visual force feedback and, consequently, a more deliberate pace of 12.05±1.73 min (P<0.001). Retraction forces, blood pressure, and heart rate were monitored throughout the procedure. Results: Full retraction resulted in an average force of 102.99±40.68 N at the standard clinical pace as compared to 64.68 N with force feedback (a 37.2% reduction, P=0.023). Standard retraction produced peak forces of 368.79±133.61 N, whereas force feedback yielded peak forces of 254.84±75.77 N (a 30.9% reduction, P=0.084). Heart rate was significantly higher during standard clinical retraction (P=0.024). Conclusions: Using the novel instrumented retractor resulted in lower average and peak retraction forces during median sternotomy. Moreover, these reduced retraction forces correlated with a reduction in animal stress as documented by lower heart rate.
St Thomas Hospital, London, UK Objectives: We previously showed that non-specific phosphodiesterase inhibition (theophylline) enhances functional recovery of rat lungs after hypothermic storage. During cardiopulmonary bypass, lungs are deflated and this may contribute to lung dysfunction post-surgery. We studied the effect of deflation on lung function and whether theophylline influenced any deflation/reinflation injury. Methods: Isolated rat lungs were perfused via the pulmonary artery (15 ml/min; 37 °C) with deoxygenated bicarbonate buffer containing rat blood (4:1, v/v) and ventilated (tidal volume 2.2 ml, 80 breaths/min) and lung function (pulmonary static compliance (Cstat), airway resistance (Raw) and gas exchange) were measured. After 20 min equilibration, ventilation was stopped (deflation) and lungs perfused with oxygenated sanguineous buffer for 0, 15, 30, 60, 90 and 120 min before re-ventilation (re-inflation) and deoxygenated reperfusion for 40 min, when recovery of lung function was measured. Further studies examined the effect of adding theophylline (3 mM) to oxygenated perfusate of lungs during deflation. Results: Increasing durations of deflation decreased recovery of lung function (Cstat was 0.37±0.07, 0.33±0.08, 0.34±0.012, 0.27±0.04*, 0.1±0.06* and 0.08±0.04* ml/cm H2O: Raw was 0.24±0.04, 0.31±0.05, 0.35±0.09, 0.43±0.01, 0.55±0.06* and 1.51±0.84* cm H2O/(ml/min): gas exchange was 68±4.81, 51±5.72, 43±16.15, 34±14.87*, 14±6.06* and 0 mmHg for 0, 15, 30, 60, 90 and 120 min, respectively (*P<0.05 compared to 0 min). Selecting 90 min of deflation, addition of theophylline significantly improved recovery (Cstat: 0.25±0.08* vs. 0.08±0.02 ml/cm H2O; Raw: 0.32±0.02* vs. 0.49±0.09 cm H2O/(ml/min); gas exchange: 38.9±7.82* vs. 10.8±4.6 mmHg [*P<0.05]). Conclusions: Deflation induces significant lung dysfunction, suggesting that deflation per se has a damaging effect on the lung. The non-specific phosphodiesterase inhibitor theophylline attenuated this injury.
University of Pittsburgh, Pittsburgh, USA Objectives: Tissue engineered matrices have been successfully applied as a scaffold to be used for cardiac patch repair and constructive myocardial remodelling has been demonstrated. We performed electromechanical characterisation of porcine urinary bladder-derived extracellular matrix (ECM) cardiac patch implanted into the porcine right ventricle. We were specifically interested in evidence of electrical activation within the remodelled patch. Methods: The ECM patch (2.5 cm x 2.5 cm) was implanted into the porcine right ventricular wall (n=5) on the beating heart through a right mini-thoracotomy. Electromechanical mapping was performed using the NOGA system (Biosense-Webster) eight weeks after patch implantation. Linear local shortening (LLS) was recorded to assess regional contractility within the patch. After sacrifice, detailed histological examination was also performed. Results: All animals survived without complications for eight weeks until their sacrifice. No infection or aneurysmal changes were noted within the patch at sacrifice. Histological examination demonstrated significant repopulation of cells that consiste d of a monolayer of Factor VIII-positive cells and multi layered a-smooth muscle actin-positive cells beneath the monolayer cells. Electromechanical mapping demonstrated that the patch had low-level electrical activity in the central area and moderate activity in the margin between the patch and the normal myocardium. Linear local shortening was –2.13%±0.85% within the patch and 14.14%±1.31% in the normal myocardium (P<0.001). Conclusions: Constructive myocardial remodelling within the ECM patch was confirmed based on repopulation of actin-positive cells. For the first time, we also observed early signs of electrical remodeling within the right ventricular patch area. Future work will focus on longer-term follow-up and ECM conditioning with fibronectin hepatocyte growth factor.
1Sheba Medical Centre, Ramat Gan, Israel; 2Magen David Adom, Ramat Gan, Israel; 3Sorasky Medical Centre, Tel Aviv, Israel Objectives: Postoperative sternotomy infection remains a significant complication causing considerable morbidity and mortality. We reviewed our experience with a new therapeutic modality of local injection of activated macrophage suspension (AMS) in treatment of deep open sternal wound infection in a retrospective case-control study. Methods: Ninety-seven patients with deep sternal wound infection (mean age 64.4 years) were treated by AMS (Group 1) during 1/2000-12/2005 while 64 similar patients (mean age 62.8 years) underwent surgical sternoplasty with various regional flaps (Group 2) during January 1998 to January 2002. Mode of therapy was guided by surgeon's preference. Despite initial anecdotal bias for surgical sternoplasty, both groups were matched for gender, age, and risk indices. AMS was prepared from osmotically shock-treated buffy coat white cells. AMS single administration was given in 28% patients, 72% received 2 or 3 administrations at intervals of 1 month. Follow-up extended up to 72 months. Results: In Group 1, 94 / 97 patients (94%) achieved complete wound closure. Two (3%) late deaths occurred unrelated to lesion or procedure. Mortality in Group 2 (sternoplasty) was 29.7% (19/64). Hospital stay was 22.6 days in Group 1, vs. 56.2 days in Group 2. Each AMS injection cost about 200 $US. Conclusions: Treatment with AMS in patients with deep sternal wound infection following open heart surgery led to significantly less mortality and significant reduction of hospitalisation and costs compared to the surgically treated group. Efficacy of the bioactive AMS treatment over conventional surgical techniques was evaluated to establish its advantages.
1Medical University of Vienna, Vienna, Austria; 2Albert Einstein College of Medicine, New York, NY, USA Objectives: Skeletal myoblasts are frequently used in the repair of ischaemic myocardium. Colony stimulating factor (CSF)-1 accelerates angiogenesis, extracellular matrix remodeling and myoblast proliferation and could therefore be beneficial in the repair of myocardium. We hypothesised that myoblasts over-expressing CSF-1 may improve cardiac function in ischaemia-induced heart failure via enhancement of angiogenesis and myocardial remodeling. Methods: Three weeks following myocardial infarction, rats developed heart failure and received intramyocardial injections of recombinant human CSF-1, a mouse CSF-1 expression plasmid, tissue culture medium or autologous rat myoblasts transfected with mouse CSF-1 or GFP expression plasmids. Tissue mRNA and protein expression was measured by quantitative RT-PCR and Western blotting. Immunocytochemistry was used to analyse myoblasts, endothelial cells and macrophages and trichrome Goldner staining to assess infarct wall thickening and collagenisation. Left ventricular function (LVF) was measured by echocardiography over time. Results: LVF improved significantly only in the CSF-1-overexpressing myoblast group (P<0.001). Rats receiving CSF-1-transfected myoblasts developed increased infarct wall thickness compared to all other groups (P<0.014). In the zone bordering the infarct, enhanced angiogenesis evaluated by the amount of proliferating endothelial cells, together with increased macrophage recruitment and over-expression of matrix metalloproteases (MMP)-2 (P=0.006) and MMP-12 (P=0.039) were only observed in the CSF-1 transfected myoblast group. Conclusions: We demonstrate that autologous intramyocardial transplantation of CSF-1 over-expressing myoblasts significantly improves LVF and might therefore represent a novel therapeutical strategy to regenerate the failing heart.
1Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria; 2Department of General Surgery, Vienna, Austria; 3Department of Cadiothoracic Surgery, Vienna, Austria; 4Department of Pathology, Vienna, Austria Objectives: Ischaemia/ reperfusion (I/R) injury due to cardioplegic arrest is a major problem in patients with reduced LV function. Hence I/R injury is in part mediated by endothelin-1 we investigated the effect of chronic versus acute administration of the selective endothelin-A receptor antagonist TBC-3214Na during I/R in failing hearts. Methods: Male Sprague-Dawley rats underwent coronary ligation. Three days post myocardial infarction the animals were randomised into three groups: Group 1 (n=6) was administered TBC-3214Na continuously with their drinking water, Groups 2 and 3 received placebo. Seven weeks post myocardial infarction the animals were evaluated on a red cell perfused working heart during 60 min of ischaemia followed by 30 min of reperfusion. In Group 2 (n=6) TBC-3214Na and in Group 3 placebo (n=6) was added to cardioplegia during ischaemia. Results: Infarct size was similar with 46±4% of LV mass. Postischaemic recovery of cardiac output (Group 1: 91±10%, Group 2: 86±11% vs. placebo: 52±15%; P<0.05) and external heart work (Group 1: 90±10%, Group 2: 85±13% vs. placebo: 51±17%, P<0.05) group was significantly enhanced in both TBC-3214Na-treated groups while recovery of coronary flow was only improved in Group 2 (Group 2: 121±23% vs. Group 1: 75±13%, placebo: 64±15%, P<0.05). High energy phosphates were significantly higher in both TBC-3214NA-treated groups. Transmission electron microscopy revealed less ultrastructural damage under TBC-3214Na. Conclusions: Both chronic and acute endothelin-A receptor blockade attenuate I/R injury in chronically failing hearts which might be an interesting option for patients with heart failure undergoing cardiac surgery.
056 - O PREDICTORS OF ASCENDING AORTIC DILATATION WITH BICUSPID AORTIC VALVE: A WIDE SPECTRUM OF DISEASE EXPRESSION A.D. Corte, C. Bancone, C. Amarelli, C. Quarto, G. Dialetto, F.E. Covino, G. Caianiello, M. Cotrufo Department of Cardiothoracic and Respiratory Sciences, Second University of Naples V, Monaldi Hospital, Naples, Italy Objectives: This study aimed to describe the features and identify the predictors of ascending dilatation in patients with bicuspid aortic valve (BAV). Methods: In 280 patients with isolated BAV undergoing echocardiography, multivariate logistic regression models, including clinical and echocardiographic variables, were developed to define predictors of dilatation (aortic ratio exceeding 1.1) at mid-ascending and root level. Classification tree models were used to identify subgroups of patients with different probabilities of having a small, normal, or dilated aorta. Factors predicting presence of aneurysm with surgical indication were also investigated. Results: Aortic dilatation was present in 83.2% patients, localised at the mid-ascending tract in 83.7% of them. Surgical indication criteria were reached in 43.2% patients, whereas a small aortic root was found in 5.7%. Increasing age (maximal risk at 50–60 years: OR=13.7) and severe aortic stenosis (OR=23.8) independently predicted mid-ascending dilatation (P<0.001). Male gender (OR=4.1, P=0.001), age >60 (OR=2.6, P=0.022), severe aortic regurgitation (OR=3.9, P=0.011) and mid-ascending dimensions (OR=18.3, P<0.001) were determinants of root involvement, while stenosis (>mild; OR=0.3, P<0.001) was a protective factor. Classification analysis showed that different age rank, gender and valve function characterised subgroups of patients with significantly different prevalence of small, normal or dilated aorta. Male sex (OR=3.1), aortic stenosis (any degree, OR=2.8) and hypertension (OR=4.0) predicted aneurysm reaching surgical indication. Conclusions: BAV patients constitute an heterogeneous population with respect to risk and features of aortic dilatation. Surgical treatment may address only mid-ascending dilation and spare the root in most patients, especially in those younger than 60 years and with aortic stenosis.
1Cardiac Surgery Department, S Orsola Malpighi Hospital, Bologna, Italy; 2Department of Cardiac Anaesthesiology, S Orsola Malpighi Hospital, Bologna, Italy Objectives: Although Antegrade Selective Cerebral Perfusion (ASCP) has been demonstrated to be the best method of protection of brain ischaemia during aortic arch surgery, there is no consensus regarding optimal temperature during ASCP. The study analysed the outcomes of aortic surgery using ASCP at different degree of systemic hypothermia.
Methods: Between November 1996 and Nvember 2005, 305 patients underwent thoracic aorta surgery using ASCP. Patients were divided into two groups according to lowest systemic temperature: moderate systemic hypothermia ( Results: The extension of aortic replacement was significantly wide in Group A, while the median ASCP time was not different between groups (63±37.7 min Group A, 58.6±35.6 min Group B; P=0.314). The 30-day mortality was 12.7% in Group A and 13.8% in Group B (P=0.862). Permanent neurologic deficits occurred in 8 patients (2.6%) without significant differences between groups (3.1% Group A vs. 0.6% Group B; P=0.715).Twenty-five patients (8.2%) suffered from temporary neurologic dysfunction (7.9% Group A vs. 8.6% Group B; P=0.833). Conclusions: In our experience, ASCP was a safe technique for thoracic aorta surgery allowing complex aortic repairs to be performed with good results in terms of hospital mortality and neurologic outcomes. The lack of differences between the two groups suggests that moderate systemic hypothermia (>25 °C) appears to be a safe and sufficient tool for brain protection. Moreover, the well known hypothermia-related side effects may be avoided.
1Uppsala University Hospital, Uppsala, Sweden; 2Uppsala Clinical Research Centre, Uppsala, Sweden Objectives: To investigate surgical and long-term mortality and associated risk factors in a large, unselected, contemporary cohort. Methods: From a national heart surgery register, all patients operated on the proximal thoracic aorta 1992–2004 were identified, and data cross-linked with in-patient and cause-of-death registers for complete cross-sectional follow-up. Factors associated with surgical (60 days) and long-term death were analysed with Cox proportional hazards analysis. Actuarial survival was analysed with Kaplan-Meier methods. Results: Overall 2634 patients: 1780 (68%) men, mean age 60 years, proximal aortic aneurysms (n=1821, 69%) and dissections (n=813, 31%). Emergency status (hazard ratio [HR] 3.8), renal failure (HR 4.7) and stroke (HR 2.5) were independently associated with surgical mortality in aneurysm patients; CABG (HR 2.2), valve replacement (HR 1.5) and stroke (HR 1.7) in dissection. Age (HR 1.05/year) was associated with mortality for both aneurysms and dissections at all stages of follow-up and the only independent predictor of long-term mortality. Later treatment era (98–04 vs. 92–97) conferred lower risk for surgical (HR 0.4) and long-term mortality (HR 0.3) in aneurysm patients only; their surgical mortality decreased from 13.7%–7.2% (P<0.0001) whereas surgical mortality for dissections remained unchanged, 22.3% vs. 22.4%. Actuarial survival (aneurysm vs. dissection) was 87% vs. 75%; 80% vs. 70%; 77% vs. 65% at 1, 5, and 10 years. Conclusions: Short- and long-term mortality improved significantly across time in patients operated for proximal thoracic aortic aneurysms, but not for dissections. Due to lower surgical mortality, long-term survival was better in aneurysm patients.
Department of Thoracic and Cardiovascular Surgery, Duesseldorf, Germany Objectives: Enlargement of the ascending aorta is often combined with valvular, coronary, or other cardiac diseases. Reduction aortoplasty can be an optional therapy, indications regarding the diameter of aorta, the history of dilatation (post-stenosis, bicuspid aortic valve), or the intraoperative management (wall excision, reduction suture, external wrapping) are not established however. Methods: In a retrospective study between 1997 and 2005 we investigated 531 patients operated for aneurysm or ectasia of the ascending aorta (35 – 76 mm). Of these, in 50 patients size-reducing ascending aortoplasty was performed. External wrapping with a non-coated Dacron prosthesis was added in order to stabilise the aortic wall. Results: Aortoplasty was combined with aortic valve replacement in 47 cases (35 mechanical vs. 12 biological), subvalvular myectomy in 29 cases, and CABG in 13 cases. The procedure was performed with low hospital mortality (0.5%) and a low postoperative morbidity. Computer-tomographic and echocardiographic diameters were significantly smaller after reduction (37.8±5.2 vs. 51.1±8.5, P<0.002), with stable performance in long-term follow-up (mean follow-up time: 36.8 months). Conclusions: As demonstrated in this study, size reduction of the ascending aorta using aortoplasty with external wrapping is a safe procedure with excellent long-term results. It is a therapeutic option in modern aortic surgery in patients with poststenotic dilatation of the aorta without impairment of the sinotubular junction of the aortic valve and root.
Kobe University, Kobe, Japan Objectives: Total arch replacement for aneurysm of distal aortic arch through midsternotomy has several advantages in cerebral, myocardial and recurrent nerve protection over left thoracotomy. However, distal extension of the aneurysm requires different approach. In this study, feasibility of midsternotomy for the distal arch aneurysms was retrospectively investigated. Methods: From October 1999 to March 31, 143 patients underwent surgery for non-dissection aneurysm of the distal aortic arch. One hundred and thirty-eight patients had midsternotomy only. The aneurysm consisted with 80 fusiform and 63 saccular type. All patients underwent total arch replacement using branched graft; 107 had antegrade cerebral perfusion and 36 had deep hypothermic circulatory arrest with retrograde cerebral perfusion. Distal anastomosis was performed under circulatory arrest of the lower body. The distance of the distal suture line from the carina was measured in pre- and postoperative CT images. Results: There were 6 early deaths (4.1%). No patients required additional skin incision or left pleurotomy. The diameter of the aneurysm was 63.5±10.1 mm. The preoperative distance from the distal end of the aneurysm to the upper edge of the carina (D1) was 13.3±10.1 mm and postoperative distance from the distal end of the graft to the upper edge of the carina (D2) was 9.3±8.6 mm (P<0.0001). Difference (D1–D2) was 4.1±8.5 mm. Mean circulatory arrest time (T) was 36.7±9.8 min. There was no correlation between the D1, D2 and T. Conclusions: The aneurysm of the distal aortic arch was accessible from the midsternotomy if the distal end of the aneurysm was located around the carina. However, the longer duration of circulatory arrest was required from the midline when the aneurysm was located deeper.
Deutsches Herzzentrum Berlin, Berlin, Germany Objectives: We analysed Marfan patients who underwent multiple operations at our institution because of progression of the disease. Methods: Retrospectively, 131 Marfan patients were analysed. Twenty-eight patients (21%) (median age 31, range 13–56 years) underwent multiple operations. Reasons for primary operation were: type A aortic dissection in 11, ascending aneurysm in 16 and abdominal aortic aneurysm in 1 patient. Results: Sixteen patients required a second, 5 patient's a third, 5 patient's a fourth and 1 patient a fifth aortic operation. After primary operation, patients subsequently underwent replacement of aortic arch/descending aorta (12 pts), descending aorta (7 pts), thoracoabdominal aorta (6 pts), abdominal aorta (6 pts) or ascending aorta (6 pts, 4 redo-op). Ten patients underwent heart transplantation (HTx) after ascending aortic replacement (all pts), mitral valve replacement or repair (4 pts), thoracoabdominal aortic replacement (2 pts) and VAD support (3 pts). In 2 patients thoracoabdominal aortic replacement was performed after HTx. There were no early deaths after primary operation and 1 early death after HTx. Seven early deaths occurred after the last aortic operation. There were no early deaths following third and fourth operation. The survival rate was 69% at 1 year and 62% at 5 years for aortic operations and 79% and 70% after HTx, respectively. Conclusions: Multiple aortic operations in Marfan patients can be accomplished with low mortality. HTx can be performed following multiple aortic operations with a good long-term survival rate. Close follow-up of all Marfan patients is important because approximately 20–25% of patients need further operations after primary vascular manifestation.
Mount Sinai School of Medicine, New York, USA Objectives: Understanding the ability of the paraspinal anastomotic network to provide adequate spinal cord perfusion pressure (SCPP) is critical for both surgical and endovascular repair of thoracoabdominal aneurysms (TAA). Methods: To monitor pressure in the collateral circulation, a catheter was inserted into the distal end of the divided first lumbar segmental artery (SA) of 10 juvenile Yorkshire pigs (28.9±3.8 kg). SA pairs from T3 through L5 were serially sacrificed at 32 °C; SCPP and function – using motor evoked potentials (MEP) – were continuously monitored until 1 h after clamping the last SA. Intermittent aortic and SCPP monitoring was continued for 5 days postoperatively, along with evaluation of motor function. Results: A mean of 14.4±0.7 SAs were sacrificed without loss of MEP. SCPP (mmHg) dropped from 68±7 before SA clamping (77% of aortic pressure) to 22±6 at end-clamping, and 21±4 after 1 h, reaching its lowest point, 19±4—after 5 h. Postoperatively, SCPP recovered to 33±6 at 24 h; 42±10 at 48 h; 56±14 at 72 h; 62±15 at 96 h, returning to baseline (63±20) at 120 h. Despite comparable SCPP. patterns, 4 pigs did not fully regain the ability to stand. Six animals recovered: 2 could stand and 4 could walk. Conclusions: Interruption of all SAs at 32 °C in this pig model results in a spectrum of cord injury, with normal function in most pigs postoperatively. The short duration of low SCPP suggests that haemodynamic manipulation lasting only 24–48 h may allow routine complete preservation of normal cord function despite sacrifice of all SAs.
Deutsches Herzzentrum Berlin, Berlin, Germany Objectives: Endovascular grafting of the aorta offers a less invasive alternative to open chest surgery. We compare the results of conventional surgical repair and endovascular treatment of acute traumatic aortic rupture. Methods: Retrospectively, 66 patients with acute traumatic aortic rupture were analysed. Most had rupture limited to the isthmus, and severe associated injuries. Thirty-five patients (31 male, mean age 38 years) underwent surgical repair, two without cardiopulmonary bypass. In 31 patients (26 male, mean age 36 years) thoracic endografts were implanted. Results: Injury severity score (ISS) and time interval between trauma and treatment were comparable in the two groups. Postoperatively, the complication rate was higher in the surgical group (28.5% vs. 3.2%). Thirty-day mortality was 22.8% (surgical group) and 6.4% (endovascular group). Main cause of death in the surgical group was brain-death in severely traumatised patients (5/8 deaths). No paraplegia occurred in either group. Stent-graft implantation was successful in all cases, except one in which emergency conversion to conventional surgery was necessary because of immediate rupture. In 9 patients the left subclavian artery was covered with the graft. One patient underwent surgical repair 15 days after endografting and one had endoleak typ Ia with further hospitalisation. Conclusions: The outcome of treatment with endovascular stent-grafts in traumatic aortic rupture appears to be better than that of conventional surgical repair, especially in patients with high risk for cardiopulmonary bypass. Stent-grafting should be performed by the cardiothoracic surgeon in the operating room, allowing rapid conversion to conventional surgery in case of complications.
Heart Institute of Sao Paulo, University Medical School, São Paulo, Brazil Objectives: Ischaemic preconditioning has demonstrated neuroprotective effects in spinal cord ischaemia. This study compares the effects of immediate ischaemic preconditioning, based on somatosensory evoked potentials monitoring, with those of cerebrospinal fluid drainage in a model of descending thoracic aorta occlusion in dogs. Methods: Eighteen dogs were submitted to spinal cord ischaemia induced by descending thoracic aorta cross-clamping for 60 min. Control group underwent only the aortic cross-clamping (n=6). Group A underwent three equal cycles of ischaemic preconditioning (n=6) and Group B underwent cerebrospinal fluid drainage (n=6), immediately before the aortic cross-clamping. Neurologic status was assessed by an independent observer according to Tarlov score. The animals were sacrificed and spinal cord harvested for histopathology. Results: Aortic pressures before and after the occluded segment were similar in the three groups. Seven days after the procedure, Tarlov scores were significantly higher in comparison to the control group only in Group B (P=0.016). Lower values of somatosensory evoked potential recovery times were also observed with the use of cerebrospinal fluid drainage during the final reperfusion period (P=0.005). Haematoxylin and eosin stain showed less important neuronal necrosis in the thoracic and lumbar grey matter in animals submitted to both methods of spinal cord protection, being more pronounced in group B (P<0.001). Tunel reaction for apoptotic neurons showed similar results for the three groups. Conclusions: Cerebrospinal fluid drainage and immediate ischaemic preconditioning seems to protect spinal cord during descending thoracic aorta cross-clamping. Nevertheless, the obtained level of spinal cord protection seems to be more significant with cerebrospinal fluid drainage.
Department of Thoracic and Cardiovascular Surgery, Westgerman Heart Centre, University of Essen, Essen, Germany Objectives: The hybrid operation theatre represents a completely new type of cardiovascular OR combined with a fully equipped cathlab. In life threatening aortic disease diagnostics and surgical therapy, as well as interventional procedures are performed simultaneously without delay or further transferral. Methods: Between April 2004 and March 2006, 73 patients with suspected acute aortic syndrome were transferred immediately to the hybrid OR. To confirm diagnosis, a TEE was performed as a primary screening. Twenty-nine patients (39%) were scheduled for emergent surgery (22 acute type A AD, 7 contained ruptured aneurysms). For suspected concomittant coronary artery disease, a coronary angiography was performed simultaneously in 15 pts (51%). An abdominal aortic fenestration for malperfusion was performed in 4/29 patients (13%) prior to surgery. Retrograde aortic stent grafting was performed in 38 patients (52%) for acute type B AD, in 8 pts (21%) under emergency conditions. Results: In 6 patients an aortic disease was ruled out. 9/29 patients (30%) operated upon received a coronary stent, 5 pts (16%) received a CABG procedure. Hospital mortality was 14% (4 pts) for surgical patients and 5% (2 pts) in the stent group. Mortality for surgical patients with a interventional based treatment of organ ischaemia preoperatively was only 7% (2 pts). Conclusions: In acute aortic syndromes diagnosis and therapy can be achieved simultaneously in a hybrid OR, integrating surgical and interventional methods, especially in specific situations like abdominal aortic malperfusion. This means a major impact resulting in shortened and improved processing with a complex disease. The results have to be reviewed.
066 - I CHRONIC HYPOXAEMIA ALONE IS SUFFICIENT TO INCREASE VENTRICULAR LEVELS OF BRAIN NATRIURETIC PEPTIDE (BNP) PRECURSORS IN NEONATAL SWINE A.R. Khan, M. Birbach, R.F. Ittenbach, P.l.R. Gallagher, M.S. Cohen, T.L. Spray, R.J. Levy, J.W. Gaynor The Children's Hospital of Philadelphia, Philadelphia, USA Objectives: Circulating levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) are elevated in patients with cyanotic congenital heart disease (CHD) and correlate with the severity of left ventricular (LV) dysfunction. We evaluated the effect of chronic hypoxaemia on LV pro-ANP and pro-BNP, the cytoplasmic precursors of the plasma hormones. Methods: Forty newborn piglets were randomised to placement of a pulmonary artery to left atrium shunt to create hypoxaemia or sham thoracotomy. Animals were studied at 1 or 2 weeks post procedure (4 groups, n=10 per group). Arterial oxygen tension (PaO2) and haematocrit (HCT) were determined. Left ventricular shortening fraction (LVSF) was measured by echocardiography. LV tissue was harvested and cytoplasm was extracted. Pro-BNP levels were determined by Western blots. Pro-ANP levels were determined using enzyme-linked immunosorbant assay. Results: Significant differences across treatment groups were observed for PaO2 (P<0.001) and HCT (P<0.001). Pairwise comparisons indicated lower PaO2 and higher HCT for hypoxaemic piglets compared with controls at 1 and 2 weeks. LVSF was not decreased in the hypoxaemic animals at any time (P=0.638). LV pro-ANP was decreased in hypoxaemic piglets (P=0.024). LV pro-BNP was increased in hypoxaemic piglets at 2 weeks (P=0.002). Conclusions: Chronic hypoxaemia alone, even in the absence of cardiac dysfunction, is sufficient to increase ventricular levels of pro-BNP. This finding may have implications for the use of BNP levels to assess clinical status of patients with CHD.
1The University of Oklahoma, Oklahoma City, USA; 2The University of Pennsylvania, Philadelphia, USA; 3The University of Miami, Miami, USA; 4The Children's Hospital of Philadelphia, Philadelphia, USA Objectives: To determine the optimal rate of low flow hypothermic cardiopulmonary bypass (LF) following circulatory arrest (CA) on brain oxygenation (bO2), extracellular dopamine (DA) and phosphorylation of CREB, ERK1/2, Bcl-2, Bax and Akt. Methods: Newborn piglets were placed on CPB and cooled to 18 °C. The animals were subjected to 30 min of CA followed by 1 h of LF at 20, 50 or 80 ml/kg/min, rewarmed, separated from CPB, and maintained for 2 h. The bO2 was measured by quenching of phosphorescence, DA by microdialysis, phosphorylation of CREB, ERK1/2, Bcl-2, Bax and Akt by Western blot. The results are means (7)±S.D. Results: Pre-bypass bO2 was 47.4±4.2 mmHg and decreased during CA to 1.9±0.8 mmHg. At the end of LF at 20, 50 and 80 ml/kg/min, bO2 was 11.8±1.6, 26±1.8 and 33.9±2.6 mmHg, respectively. A 51.050±22.590% (P<0.001) increase in DA was observed at 15 min of LF20 and was maximum at 45 min. With LF50 the increase in DA was not significant and was completely abolished by LF80. Bcl-2 immunoreactivity increased after LF50 and LF80 (140±14.5%, P<0.05 and 202±34%, P<0.05, respectively). Neither flow increased Bax immunoreactivity. The ratio of Bcl-2/Bax and levels of p-CREB, pAkt, pERK increased significantly with increased rate of LF. Conclusions: The protective effect of LF following CA on brain metabolism is dependent upon the flow rate. Flow dependent increase in pCREB, ERK1/2, Akt, Bcl-2/Bax ratio and decrease in DA indicate that to minimise CA dependent neuronal injury, the rate of LF should be greater than 50 ml/kg/min.
1Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan; 2Department of Anaesthesiology, Kitasato University School of Medicine, Sagamihara, Japan; 3Department of Clinical Engineering, Kitasato University School of Medicine, Sagamihara, Japan Objectives: Regional cerebral low flow perfusion (RLFP) has been shown to provide cerebral circulatory support during aortic arch reconstruction. However, its ability to provide renal circulatory support remains unknown. We studied the relationship between cerebral oxygen saturation (rSO2) and renal function during RLFP. Methods: Between December 2002 and November 2005, 12 patients aged from 3 to 61 days (median, 11 days) and weighing 1.9–3.4 kg (median, 2.8 kg) underwent aortic arch reconstruction using RLFP. The rSO2 was monitored by near-inflated spectroscopy during cardiopulmonary bypass (CPB). Pump flow rate was adjusted to maintain mean right radial arterial pressure (RAP) between 30 and 50 mmHg during RLFP. Data were assigned to either of 2 groups according to their corresponding rSO2: Group 1 (rSO2 <75%, n=6) and Group 2 (rSO2 <75%, n=6). Results: Pump flow rate was similar in both groups, (Group 1, 79±23 vs. Group 2, 70±23 ml/(kg/min); P=0.4), The mean RAP in Group 1 was lower than in Group 2, (Group 1, 34±5.2 vs. Group 2, 46±7.1 mmHg; P=0.04). However, the urinary output in Group 1 was greater than that in Group 2, during RLFP (Group 1, 1.4±1.6 vs. Group 2, 0.02±0.05 ml/(kg/min); P=0.04). Conclusions: Our study revealed that higher cerebral oxygenation preserved sufficient renal blood flow through collateral circulation. More than 75% rSO2 should be targeted during RLFP.
1Institute of Cardiology, Warsaw, Poland; 2ICM Warsaw University, Warsaw, Poland; 3Faculty of Power and Aeronautical Engineering, Warsaw University of Technology, Warsaw, Poland Objectives: Retrospective analysis of 68 cases of mBT anastomosis revealed differences in geometry of anastomosis that may result in alter flow patterns and may consequently lead to platelet activation and graft closure. Analysis of the medical, biochemical, and geometric data suggested some geometric differences between the prosthetic grafts although beyond statistical significance. The difference in the geometry of anastomosis may result in altered flow patterns, which in turn may lead to activation of platelets and the clotting cascade. Methods: Computer models represented the averaged geometry of the graft in two groups of patients. Numerical simulations of blood flow in both models were performed using computational fluid dynamics software. About 80% of inflowing blood was directed to the pulmonary circulation. Shear stress fields were calculated, and the volume within the model with high shear rate (over 2500 1/s) was determined, in different phases of the cardiac cycle. Results: In both models we observed a large recirculation region at the inlet to the graft accompanied by a high shear stress region at the opposite wall of the graft inflow. The region of high stress was less than 0.5% of total volume of the system in model A, and over 4% of total volume in model B. Conclusions: Narrow and long grafts create flow patterns with high shear stress that promote platelet activation leading to augmented risk of clot formation. Therefore the graft geometry may be one of crucial factors in mBT anastomosis failure.
1Royal Brompton Hospital, London, UK; 2National Cardiovascular Centre, Osaka, Japan Objectives: To determine structural features and variations in the mitral valve guarding inflow of the morphologically left ventricle in hearts with discordant atrioventricular connections. Methods: Morphologic investigation was carried out in 47 autopsied specimens with this particular atrioventricular connection. Results: The tension apparatus was straddling to the morphologically right ventricle in two. Another 32 hearts had the papillary muscles abnormally oriented, although pattern of closure of the leaflets was normal; a solitary papillary muscle in two, two papillary muscles but deviated in eight and three or more papillary muscles in 22. The origin of the papillary muscles was frequently deviated. In five hearts with abnormal pattern of closure of the leaflets, multiple papillary muscles were also the case. One of these had a marked downward displacement of the annular attachment as seen in Ebstein malformation of the tricuspid valve. The mitral valve was normally structured in only eight hearts (17%). There was no obvious correlation noted between the presence of abnormality in the mitral valve and that in the tricuspid valve. Morphologic feature of ventricular septal defect did not affect presence or absence of abnormality in the mitral valve, either. In contrast, finding of an unusual mitral valve was less common in hearts with pulmonary atresia with the aorta arising from the right ventricle, compared to those with double outlet or discordant ventriculo-arterial connection. Conclusions: Architectural abnormalities are not rare in the morphologically mitral valve in this setting. The valvar structure needs precise recognition when determining a surgical strategy for definitive repair.
1Department of Cardiovascular Surgery of the University Hospital, Freiburg, Germany; 2Memorial Hospital Childs Health Centre, Warsaw, Germany; 3Department of Paediatric Cardiology of the University Hospital, Freiburg, Germany Objectives: Gender outcome differences following congenital heart surgery have been investigated in detail. It was not possible to identify important differences even though a different hormonal-biologic activity or sociocultural effects might indicate a distinct postoperative course. A drawback of the studies was a limited case load. Therefore, we analysed the data from the EACTS congenital database concerning gender outcome differences. Methods: We analysed all data available from the EACTS congenital database including a total of 30,036 procedures. We screened following population subgroups on 30-days mortality: age (neonates, infants, older than 1 year), diagnoses (top 10 diagnoses from the database), and country of treatment. We did statistics (proportional test) using R packages. P<0.05 was regarded significant. Results: Global 30-day mortality did not differ between girls (659/13,780=4.8%) and boys (837/16,256=5.1%). In neonates, we detected a significant higher female mortality (319/2280=14.0%) compared to males (407/3377=12.1%); even, though we counted more male HLHS as a diagnosis contributing significantly to neonatal mortality. Conversely, mortality of children over 1 year was higher in boys (182/7840=2.3%) compared to girls (123/6977=1.8%). In infants, there was no difference. Analyzing the top 10 diagnoses, only after correction of coarctation the mortality differed in gender: girls 3.5%, boys 1.6%. From the high volume countries, Poland was the sole to have gender differences with higher mortality of boys (4.4% vs. 2.7%). Conclusions: Using the EACTS congenital database, we were able to reveal important gender differences in 30-day mortality following congenital heart surgery. Multivariate analysis must follow to identify gender as a proper risk factor in subgroups.
Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan Objectives: Potential drawbacks from RV-PA conduit in modified Norwood procedure may be regurgitation through the conduit and incision at the systemic ventricle. Methods: In order to address the question if valved RV-PA conduit can provide haemodynamic advantages in modified Norwood operation, we retrospectively reviewed the data of patient who underwent modified stage I Norwood operation with either non-valved ePTFE RV-PA conduit (ePTFE) or valved saphenous vein homograft (SVG) between October 2001 and December 2004. Results: Eight patients including four in ePTFE group and four in SVG group were involved in the study. Each patient died within 30 days after the surgery in both groups. Serial echocardiography and catheterization study were done. Four patients completed bidirectional Glenn procedure with two patients of Fontan completion. Conduit regurgitation was seen mild to moderate-to-severe in all patients with ePTFE group and mild in one patient with SVG group. This regurgitation progressed over the next several months in ePTFE group, whereas it remained static in SVG group. Tricuspid regurgitation became worse in ePTFE group, whereas it was improved in two patients of SVG group. RV ejection fraction was reduced from 70±4 to 55±12% in ePTFE group, whereas it was improved from 62±10 to 70±2% in SVG group postoperatively (P<0.05). Conclusions: We conclude that conduit regurgitation may cause RV systolic dysfunction and prolong a functional recovery after modified stage I Norwood procedure. SVG may be a choice as RV-PA conduit in the procedure with potential limiting factor of graft size and availability.
Centre Hospitalier Universitaire Vaudois CHUV, Lausanne, Switzerland Objectives: Peripheral cannulation in congenital cardiac surgery is limited by the dimension of the access vessel and therefore the patient's size. Actually for some patients there are no peripheral cannulae available today. We report our initial experience of femoral cannulation in paediatric patients with the self-expanding paediatric arterial and venous smartcannulaTM. Methods: Femoral cannulation was performed in five children (range 2–6 years). Peripheral venous cannulation was performed in the setting of reoperations to allow CPB support during cardiac mobilization in four patients. The interventions included an arterial switch operation after ventricular training and three Fontan completions. In the fifth patient a double ASD was closed via a minimally invasive posterior thoracotomy with femoro-femoral cannulation. Results: Body weight of the 5 patients was 16.9±3.9 kg, height was 105.8±14 cm with a BSA of 0.7±0.1 m2. The venous access vessel diameter were 5.3±1.2 mm (range 4–7 mm) the cannulated femoral artery measured 3.5 mm. Effective CPB flow was 2.2±0.6 l/min vs. a calculated theoretical flows of 1.8±0.4 l/min, corresponding to a 121±10% flow increase. Resulting in a lowest mixed venous saturation of 63.0±9.2% at a minimal haemoglobin level of 82.2±4.9 g/l. Conclusions: The self-expanding design of the paediatric smartcannulaTM makes peripheral small vessel cannulation possible for previously inaccessible vessel sizes and generates superior flows despite of the decreased access vessel diameter.
1Clinic for Cardiovascular Surgery University Hospital, Berne, Switzerland; 2Division of Paediatric Cardiology University Hospital, Berne, Switzerland Objectives: Pulmonary regurgitation (PR) is a frequent sequela after repair of Tetralogy of Fallot (TOF) negatively affecting long-term prognosis and necessitating re-interventions. Myocardial damage, invasiveness and the risks of pulmonary valve replacement (PVR) need therefore be minimised. The new Shelhigh Injectable Stented Pulmonic Valve allows implantation without cardiopulmonary bypass under direct control. Methods: Four symptomatic patients aged (median) 14.8 (11.2–40) years with severe PR and progressive RV dilatation with dysfunction after TOF repair received the new Shelhigh Injectable Stented Pulmonic Valve in sizes 23 (n=2), 25 and 29. Results: Valve insertion was successful and haemodynamic performance excellent in all (peak systolic gradient 6.25 (4.7–11), mean gradient 2.15 (2–4.9) mmHg). One patient needed additional reduction plasty of a dilated main pulmonary artery (MPA). Early recovery was uneventful in all. One patient required reoperation 2 months later due to valve migration in a dilated, conical shaped MPA of 35mm, which had not been reduced at the time of PVR. Echocardiography after 4, 9, 12 and 18 (median 12.2, range 4.3–18.2) months showed good results with low gradients and recovered RV function in all but one patient with moderate paravalvular PR. All presented in NYHA functional class 1 at the latest follow-up. Conclusions: The new Shelhigh Injectable Stented Pulmonic Valve allows for easy PVR without cardiopulmonary bypass. Reduction plasty in the presence of dilated MPA or RVOT and external fixation are crucial to ensure proper positioning and excellent durable performance.
1Clinic for Cardiovascular Surgery, German Heart Centre, Munich at the Technical University Munich, Munich, Germany; 2Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre, Munich at the Technical University Munich, Munich, Germany; 3Department of Paediatric Cardiology, University of Ulm, Ulm, Germany; 4Department of Internal Medicine and Cardiology, University of Ulm, Ulm, Germany Objectives: Pulmonary regurgitation leads to right heart failure and arrythmias after right ventricular outflow tract (RVOT) reconstructions. A RVOT diameter of greater than 22 mm precludes currently a percutaneous approach. Methods: Six patients (10 to 27 years of age) presented with severe pulmonary regurgitation (median MRI pulmonary regurgitation 50%, range 45–64%) and huge RVOT diameters (median MRI RVEDD/m2 141 ml/m2, range 118–174 ml/m2) after previous transannular RVOT patch. After repeat sternotomy, a porcine valve mounted inside a self-expandable stent (sizes 24-31 mm), covered by No-React( treated porcine pericardium (Shelhigh, Model NR-4000MIS) was injected just beneath the RVOT without use of cardiopulmonary bypass. External sutures were placed at the proximal and distal site of the valve to ensure fixation. Results: The patients were hemodynamically stable throughout the procedure. Echocardiographic assessment confirmed the position and function of the valve. In one patient with hugely dilated RVOT (34 mm), a homograft was implanted after 2 days due to paravalvular leakage. After a mean follow-up of 6 months (0.3-11.8 months), two patients had repeat follow-up MRI after 10 months with a right ventricular volume decrease to 119 ml (previously 165 ml) and to a volume index of 83 ml/m2 (previously 138 ml/m2) and to 140 ml (previously 194 ml) and to a volume index to 87 ml/m2 (previously 141 ml/m2) with normalization of the right ventricular function (ejection fraction 61% and 56%). Conclusions: Cardiopulmonary bypass for repeat RVOT interventions can be avoided in selected patients. The newly available device in combination with a wide range of prosthesis sizes offers yet another treatment option.
076 - O EFFECT OF BILATERAL MEDIASTINAL LYMPHADENECTOMY ON PULMONARY FUNCTION J. Ku  dal1, M. Zieli ski1, B. Papla2, M. Narski1, A. Szlubowski1,  . Hauer1, J. Pankowski1 1Depatment of Thoracic Surgery Pulmonary Hospital, Zakopane, Poland; 2Department of Pathology Jagiellonian University, Krakow, Poland Objectives: To assess, if the bilateral mediastinal lymphadenectomy results in clinically significant impairment of respiratory function. Methods: In the prospective, randomised, double-blind clinical study, NSCLC patients underwent preoperatively mediastinoscopy or the transcervical extended mediastinal lymphadenectomy (TEMLA). Patients as well as the staff members recording the end-points did not know the allocation. In both groups the blood gas analysis and spirometry were measured preoperatively and on the 1st, 3rd and 5th postoperative day, and the carbon monoxide diffusing capacity of the lung (DLCO) and lung compliance were measured preoperatively and on the 3–5 postoperative day. Any respiratory complications were also recorded. Results: Forty-one patients were randomised: 21 to the TEMLA group and 20 to the mediastinoscopy group. There was no significant difference of the baseline and the 1st, 3rd and 5th day measurements for VC and FEV1 (P>0.98), pH, pO2, pCO2, standard bicarbonates and base excess (P>0.31), nor significant difference of baseline and 3–5 day measurements for DLCO (P=0.91) and lung compliance (P=0.38). The incidence of respiratory insufficiency was not significantly different (1/21 vs. 0/20, P=0.51). Conclusions: 1. Complete excision of mediastinal lymph nodes stations 1, 2R, 2L, 3a, 4R, 4L, 5, 6, 7 and 8 (TEMLA) is not associated with greater incidence of respiratory insufficiency comparing with standard mediastinoscopy. 2. The TEMLA procedure does not produce greater alterations in spirometry, blood gas analysis, DLCO and lung compliance comparing with standard mediastinoscopy.
Glenfield Hospital, Leicester, UK Objectives: To examine the short- and long-term results of right extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MM) via median sternotomy or thoracotomy. Methods: We analysed the results of EPP in consecutive patients with early stage MM undergoing a radical surgery protocol for MM over a seven-year period. Initially thoracotomy, but latterly median sternotomy, was the incision of choice for right sided tumours. The effects of the change of approach on perioperative course and survival was analysed. Results: EPP was performed in 105 patients (50 left thoracotomy, 22 right thoracotomy, 28 sternotomy, 5 combined sternotomy and right thoracotomy). Operation time was faster with median sternotomy than right thoracotomy (P=0.007). Right thoracotomy was associated with higher pain scores and epidural infusion volume (P<0.0001) than median sternotomy. There were no differences in pathological stage, postoperative morbidity or duration of postoperative stay. Median survival following left thoracotomy, right thoracotomy and median sternotomy was 658, 259 and 537 days, respectively (P=0.002). Planned neoadjuvant or adjuvant chemotherapy was more common following median sternotomy than right thoracotomy (P=0.02). However, right EPP performed via a sternotomy alone was an independent predictor of good prognosis (Hazard Ratio 2.9 (95%CI 1.3–6.2), P=0.008). No wound complications or wound seedling have been observed following median sternotomy. Conclusions: Right EPP should be performed via median sternotomy.
Papworth Hospital NHS Trust, Cambridge, UK Objectives: To assess if individual case volume of oesophageal resections for cancer influences the risks of mortality. Methods: Between January 1994 and March 2006, 205 oesophageal resections (73% male, mean age 63 years) were performed by 9 surgeons in a single institution. Operative mortality, defined as in in-hospital death, was compared between the high volume (15 or more oesophageal resections per year) and low volume (14 or less per year) surgeons. Multivariate logistic regression was used to analyse the risk factors for death between the 2 groups. Results: Two high volume surgeons performed 121 (59%) of the operations with a mean of 15/year compared to 7/year in the low volume group. The patients in the two groups (121 high volume vs. 84 low volume group) were well matched for mean age (65.5 vs. 60.5), sex (59% vs. 58% male) and tumour type (62% vs. 71% adenocarcinoma; P=0.16). Ivor Lewis resections were performed more frequently by high volume surgeons (96% vs. 68%; P<0.001). The overall morbidity was similar (30% vs. 31%; P=0.86), however, the hospital mortality rate was much lower when high case volume surgeons performed the procedure (3% vs. 17%; P=0.001). The relative risk of death when low volume surgeons performed the procedure was 5.04 (95% CI 1.72–14.78; P<0.001). Multivariate analysis revealed that individual surgeon's case volume was an independent risk factor for death. Conclusions: Operative mortality rate for oesophagectomy for cancer was strongly influenced by case volume and was 5 fold higher when performed by surgeons with low case volume.
1Department of Surgery, University Szeged, Szeged, Hungary; 2Department of Pathology, University Szeged, Szeged, Hungary; 3Department of Pathology, Humboldt University, Berlin, Germany; 4Institute of Pathology, University Freiburg, Freiburg, Germany; 5Institute of Physiological Chemistry, Ludwig Maximilians University, Munich, Germany Objectives: To investigate the role of growth/adhesion-regulatory lectins in the prognosis of the stage II non-small cell lung carcinomas via quantitative lectinhistochemical examinations and measurement of microvascularisation of the tumour. Methods: In 94 radically operated lung cancer patients, stage II NSCLC was confirmed histologically (T1N1: 6, T2N1: 66, T3N0: 22). Immunohistochemical methods were applied to investigate the galectin-1, galectin-3, CL-16 and hyaluronic-acid-binding capacities of the tumours, and also the expression of galectin-1, -3 and heparin-binding-lectin. Sections were examined with the aid of qualitative (stained/not-stained) and syntactic structure analysis. The microvessels were detected by staining with anti-factor VIII antibodies. The findings were compared with the survival data. Results: In the univariate survival examinations, the prognosis was poorer for the galectin-1 and -3-expressing tumours (P=0.014 and P=0.003) and in multivariate analysis for the galectin-3-expressing tumours (P=0.046, RR: 2.026). Correlations could be demonstrated between the survival and the distance between the tumour cell for the tumours binding galectin-3 (P=0.039, RR: 5.944) and expressing galectin-3 (P=0.041, RR: 3.335). An elevation of the volume fraction of microvessels was a sign of a poor prognosis (P=0.017, RR: 2.334), however the increase of surface fraction improves the survival (P=0.01, RR: 0.956). Conclusions: In stage II NSCLC, galectin-3 expression is indicative of a poor prognosis. In tumour expressing and binding galectin-3, the distance between the tumour cells is of prognostic significance. An increase in the microvessel volume fraction points to a poorer survival rate.
King Abdulaziz Medical City, Riyadh, Saudi Arabia Objectives: Major thoracic surgical procedures have been rarely performed under awake anaesthesia. The purpose of this study is to review the experience of a tertiary centre in major thoracic surgical procedures done under awake anaesthesia. Methods: We reviewed all consecutive case of thoracic surgical procedures done under awake anaesthesia between 2002 and 2005. The patients were pre-medicated with intravenous fentanyl 50 µg and midazolam 3 mg. Thoracic epidural anaesthesia was done between T1-T3 and T4-T6 depending on the type of procedure. The block level was verified using warm-cold discrimination. The following data were documented: patients’ demographics, the type and approach of procedure, operative time, intra-operative complications, mortality, the need for intensive care unit (ICU) admission and post-operative hospital length of stay. Results: A total of 44 cases. The mean age was 37±18 years. 48% of patients were females. Eighteen patients (41%) of patients underwent thymectomy. The next most common procedure was lung resection in 9 patients (20%), while symphathectomy was done in 6 patients (13%). The most common approach was thoracoscopy in 37 patients (84%), followed by thoracotomy in 3 patients (7%) and median sternotomy in 2 patients (5%). The median postoperative hospital stay was 2 days, with 30% of cases were discharged on the same day of operation (day surgery). Only four patients (9%) required ICU admission. All patients were discharged alive except one patient who died later as a result of his underlying metastatic hepatocellular carcinoma. No procedure-related mortality. Conclusions: Major thoracic surgical procedure can be performed under awake anaesthesia with minimal morbidity and mortality. This approach allows early discharge of the patient and minimises the need for innsive care unit facility.
Carlo Forlanini Hospital, Rome, Italy Objectives: Some concern still exists regarding long-term lung function following videothoracoscopic talc poudrage for primary spontaneous pneumothorax (PSP). We evaluated lung function at 5 years in a series of 100 patients surgically treated for PSP. Methods: Out of 1065 patients treated for PSP by means of videothoracoscopic talc poudrage from 9/1995 to 1/2006, 50 patients (33 male, 17 female, mean age: 24.22 years, median age: 24 years; range: 13–40) (Group A) with no recurrence underwent functional evaluation with measurement of static and dynamic volumes (FEV1- FVC- TLC- RV), and DLCO at 60 months after surgery. Fifty patients (35 male, 15 female, mean age: 23.56 years, median age: 22.5 years; range: 16–37) underwent same pulmonary function tests 5 years after simple drainage for a first episode of PSP (Group B). Results: Pulmonary function test showed (mean% value for Group A vs. B): FEV1 93% vs. 95.4% (P: 0.0648); FVC 98% vs. 100.16% (P: 0.1058); TLC 91.76% vs. 94.36% (P: 0.0572); RV 97% vs. 99.2% (P: 0.0678); DLCO 91.44% vs. 91.98% (P: 0.4147). No patient in both groups showed FEV1 <80%. Conclusions: No statistically significant differences in long-term lung function have been found between patients treated with pleural drainage only vs. patients treated with videothoracoscopic talc poudrage for PSP. Lung function is not impaired by videothoracoscopic talc poudrage.
1Department of Thoracic Surgery, Regional Lung Diseases Hospital, Prabuty, Poland; 2Department of General Gastroenterologic Surgery and Nutrition, Medical Academy, Warsaw, Poland; 3Department of Thoracic Surgery, Olsztyn City Hospital, Olsztyn, Poland; 4Department of Human Nutrition, Medical Academy, Warsaw, Poland; 5Department of Surgical Research and Transplantology, Medical Research Centre Polish Academy of Sciences, Warsaw, Poland Objectives: To assess changes of interleukin 6 (IL-6) and interleukin 1 receptor antagonist (IL-1ra) in patients operated on due to lung cancer. Methods: Twenty-seven patients treated with lobectomy or pneumonectomy, including 14 with complications and 13 without complications, were analysed. Serum IL-6 and IL-1ra concentration was measured before, at the end of surgery, and on postoperative day 1, 3, and 7. Concentration of IL-6 and IL-1ra was measured in bronchial washings at the end of surgery and in drainage fluid on postoperative day 1. Results: In the entire group serum concentrations of IL-6 and IL-1ra were significantly elevated after surgery. Serum IL-6 concentration was higher in patients with complications on day 3 (1965.5±5630.9 vs. 71.1±60.2 pg/ml; P=0.022) and 7 (80.9±69.9 vs. 25.7±20.3 pg/ml; P=0.002). Patients with complications had higher concentration of IL-6 in drainage fluid (72,959.9±37,012.3 vs. 10,329.3±28,843.8 pg/ml; P=0.0003) and in bronchial washings (37,494.3±61,899.4 vs. 1836.4±2568.3 pg/ml; P=0.01). Serum IL-1ra concentration was higher in patients with complications on day 3 (7374.6±18473.2 vs. 1218.2±1263.7 pg/ml; P=0.024) and 7 (2695±3040.4 vs. 995.4±1122.2 pg/ml; P=0.016). Concentration of IL-1ra in drainage fluid was higher in patients with complications (74,597.1±33,084.3 vs. 24,206±26,543.1 pg/ml; P=0.0001). On day 1 a significant correlation between serum and drainage fluid concentration for IL-6 as well as for IL-1ra were observed (Spearman test for IL-6: r=0.47; P=0.02; for IL-1ra: r=0.48; P=0.02). Conclusions: Elevated serum IL-6 and IL-1ra concentrations reflect development of postoperative complications. Elevated concentration of IL-6 in bronchial washings, as well as elevated concentration of IL-6 and IL-1ra in drainage fluid on postoperative day 1 can be markers of complications.
Glenfield Hospital, Leicester, UK Objectives: Previous published work has confirmed the feasibility of performing a standard lobectomy in patients with NSCLC and severe heterogeneous emphysema of apical distribution whose respiratory reserve is outside operability guidelines. We now aim to determine whether this approach is justified for patients undergoing non-anatomical LVRS for severe emphysema. Methods: A review of a single surgeon's experience from 1997 to 2006 identified 30 patients who underwent upper lobectomy for completely resected stage I-II NSCLC. All patients had severe heterogeneous emphysema of apical distribution and a predicted postoperative FEV1 of less than 40%. The pre and peri-operative characteristics, post-operative spirometry and survival of these cases were compared to 45 patients who underwent unilateral upper lobe LVRS during the same period. Results: Expressed as median (range). LVRS patients were significantly younger (59[39–70] years vs. 67[48–79] P<0.001), with worse spirometry (FEV1 % pred 24[12–60] vs. 44[17–54] P<0.001) and more heterogenous disease(‘Q’ score 4 [0.5–16.5] vs. 8[1.5–13] P=0.001). No difference was found in 90-day mortality (1 vs. 2 patients, or survival (47 vs. 53 months). Lobectomy patients had a shorter air leak duration (5[2–36] vs. 9[1–40] days, P=0.02) and hospital stay (8[3–63] vs. 13[6–90] days, P=0.01). A significant correlation exists between Q score and%change in FEV1 post-op(r=–0.38, P=0.02). When stratified there was no difference in post-op%FEV1 change between the groups, in patients with a low ‘Q’ score (P=0.1) Conclusions: Anatomical lobectomy in severe emphysema is associated with similar outcomes as LVRS. Increased heterogeneity is associated with better spirometric improvement. Lobectomy for emphysema reduces in-patient stay.
Thoracic Surgery Department, European Institute of Oncology, Milan, Italy Objectives: A higher mortality has been reported after pneumonectomy over the age of 70. The aim of the study was to quantify the additional risk due to age after standard pneumonectomy for lung cancer by a case-control study. Methods: The clinical database was reviewed to search for patients aged 70 or more who underwent a standard pneumonectomy for lung cancer between 1998 and 2005. A control group of patients younger than 70 (1 case/2 controls) was matched for sex, cardiovascular disease, ASA score, respiratory function, side of pneumonectomy, induction chemotherapy and stage. Overall mortality and morbidity as well as specific morbidity (respiratory, cardiac, surgical) were compared. Results: During the considered period, 35 patients aged 70 years or more underwent pneumonectomy (30 males, median age 73 year, 15 right-sided procedures). The control group was composed of 70 patients. The 2 groups were homogeneous in the variables used for matching. Overall mortality and morbidity were 11.4% and 54.2% in the elderly group compared to 5% and 41.6% in controls (P=0.25 and 0.22, respectively). Elderly patients experienced a higher rate of respiratory complications (25.7%) compared to controls (8.3%, P=0.01). Respiratory complications were more frequent when elderly patients had a preoperative FEV1<70% compared to those having FEV1>70% (43.7% vs. 11.1%, P=0.03). Preoperative chemotherapy did not affect postoperative morbidity. Conclusions: In elderly patients pneumonectomy doubles mortality compared to younger patients, due to a dramatic increase in respiratory complications. Respiratory function has been confirmed as the most reliable predictor of morbidity.
University of Rome La Sapienza, Department of Thoracic Surgery, Rome, Italy Objectives: Induction therapy for advanced stage lung cancer allows improvement of completeness of resection and survival. However, predictive risk factors, incidence of postoperative complications and early mortality remain controversial. We report our experience with this combined approach. Methods: One hundred and thirty nine patients (100 male and 39 female) underwent induction therapy and surgery for stage III and IV lung cancer. The mean age was 58.4±7.7 years. We collected demographic data, preoperative functional parameters, type of operation, comorbidities, stage of the tumour, induction regimen (chemotherapy alone or associated with radiotherapy). Univariate and multivariate analysis were performed to identify predictors of postoperative complications and early mortality. Results: Chemotherapy was based on cisplatin and gemcitabine; the median dose of radiotherapy was 50 Gy. Complications developed in 49 patients (35%): the most frequent was persistent air leakage (23%), followed by cardiac problems, respiratory failure and infections. Five patients (3.5%) died in the perioperative period and 4 of them received pneumonectomy. The statistical analysis demonstrated that only pneumonectomy was associated with increased risk of mortality. Conclusions: Induction therapy seems to be associated to an increased incidence of air leakage; the risk of other complications is acceptable. Pneumonectomy is associated with an increased risk of mortality and should be performed in selected patients.
086 - O EARLY OUTCOME OF TRANSAPICAL AORTIC VALVE IMPLANTATION WITHOUT CARDIOPULMONARY BYPASS IN ELDERLY PATIENTS WITH END-STAGE SEVERE AORTIC STENOSIS J. Ye, A. Cheung, J. Webb, R. Carrere, C. Thompson, S. Pasupati, S.V. Lichtenstein University of British Columbia, Vancouver, Canada Objectives: Aortic valve replacement (AVR) is associated with significant operative morbidity and mortality in the elderly. Arterial access remains a challenge in many elderly patients for percutaneous aortic valve implantation (AVI). We are reporting initial outcome of AVI for aortic stenosis (AS) via the apex of the left ventricle (LV) without cardiopulmonary bypass.
Methods: Six patients (74.8±9.3 years old, frail) with end-stage AS and significant co-morbidities deemed to be non-surgical candidates for open-heart AVR and without femoral arterial access for percutaneous AVI underwent off-pump transapical AVI through a small ( Results: Valves were successfully deployed and well seated in all 6 patients. All patients recovered quickly without symptoms. Aortic valve area increased from 0.63±0.15 to 1.65±0.29 cm2 and mean gradient decreased from 36±6.2 to 10.8±5.4 mmHg at one month follow-up. No and mild paravalvular leak was observed in 4 and 2 patients, respectively. There was no mortality, perioperative complication, or blood transfusion. Conclusions: Early clinical and haemodynamic outcomes of the first series of six off-pump transapical AVI are excellent. Transapical AVI is a safe, viable and evolving surgical approach for treatment of AS.
International Heart Institute of Montana Foundation, Missoula, USA Objectives: Coronary flow obstruction is a serious complication in percutaneous aortic valve replacement. In an in vitro study of porcine hearts, the effects of stented valve implantation on diastolic coronary flow were studied both with the native leaflets intact and excised. Methods: Porcine hearts were obtained from a local abattoir. After the removal of excess tissue, the right and left main coronary arteries were dissected 20 mm distal from the aortic root and directed into lengths of latex tubing leading to collection flasks. The ascending aorta was cut proximal to the brachiocephalic trunk, cannulated, and attached to a constant-head water supply (P=60 mmHg). Once steady flow was achieved, the flow rate from each coronary was measured. In Group A (n=10), a tubular pericardial valve sutured in a cobalt-nickel stent was deployed orthotopically using a valvuloplasty balloon catheter. In Group B (n=10), the native leaflets were removed before valve deployment. Coronary flow measurement was repeated after valve implantation. Results: In Group A, valve implantation resulted in a significant decrease in both left and right coronary flow. In Group B, there was no significant change in either right or left coronary flow after valve placement. Average Change in Coronary Flow After Valve Implantation Group Left coronary Right coronary A –42.8% (P<0.003) –18.2% (P<0.02) B +1.0% (P>0.05) –1.8% (P>0.05) Conclusions: Implantation of a percutaneous valve in orthotopic position with the native valve in place caused major coronary flow obstruction. Our results suggest the need for native leaflet ablation prior to percutaneous aortic valve replacement.
University Hospital of Liege, Liege, Belgium Objectives: To assess factors influencing operative and long-term outcome in octogenarians undergoing aortic valve surgery (AVR). Methods: Records of 220 consecutive octogenarians having AVR between 1992 and 2004 were reviewed, and follow-up obtained (99% complete). Of the group (mean age: 82.8 years; 174 females), 142 patients (65%) were in New York Heart Association (NYHA) class III-IV, 22 (10%) had previous myocardial infarction, and 8 (4%) had percutaneous aortic valvuloplasty. They were 44 urgent procedures (20%), and coronary artery bypass grafting (CABG) was performed in 58 patients (26%). Results: Operative mortality was 13% (9% for AVR, 24% for AVR+CABG). Significant postoperative complications were atrial fibrillation in 48 patients (22%), respiratory insufficiency in 46 (21%), permanent atrio-ventricular bloc in 12 (5%), myocardial infarction in 10 (5%), haemodialysis in 4 (2%), stroke in 4 (2%). Median hospital and intensive care unit stays were 17.6±2.2 and 6.9±3.4 days, respectively. Multivariate predictors of hospital death were percutaneous aortic valvuloplasty, NYHA class IV, urgent procedure, and associated CABG. Mean follow-up was 58.2 months and actuarial 5-year survival was 73.2±6.9%. Preoperative myocardial infarction and urgent procedure were independent predictors of late death. At follow-up, 91% were angina free and 81% in class I-II. Conclusions: AVR in octogenarians can be performed with acceptable mortality, although significant morbidity. These results stress the importance of early operation on elderly patients with aortic valve disease, but associated coronary artery disease is a harbinger of poor operative outcome. Long-term survival and functional recovery are excellent.
Department of Thoracic and Cardiovascular Surgery, Duesseldorf, Germany Objectives: Coronary angiography in elderly patients referred to hospital for aortic valve replacement (AVR) often shows additional stenoses of the coronary arteries (CAD). The benefit of concomitant coronary artery bypass grafting (CABG) is still discussed controversially.
Methods: We analysed 323 patients ( Results: Comparing Group A and AC, we found a significantly prolonged mechanical ventilation in Group AC (23.3±5.5 h vs. 10.3±1.9 h in Group A, P<0.05) and a longer stay on ICU. The incidence of postoperative complications and the mortality were comparable. In Group AC* there was a difference between stenoses of the LAD (n=21) and of the RCA or RCX (n=35). The decision not to bypass a stenosis of the LAD caused a significantly worse outcome of these patients compared to groups A and AC (severe complications: 11.9% vs. 3.5%; mortality: 7.4% vs. 3%, P<0.05). Ignoring stenoses of the RCA or RCX was not correlated to an impaired postoperative result. Conclusions: Our results did not identify concomitant CABG as a predictor of poor surgical outcome in elderly patients with AVR. It was shown that additional bypass grafting of stenoses of the LAD is important for the outcome, whereas comparable stenoses in the RCA or RCX may be neglected.
Cardiothoracic Surgery of the University Hospital, Coimbra, Portugal Objectives: To evaluate perioperative results and long-term follow-up of complex prosthetic valve endocarditis treated by allograft aortic root replacement. Methods: From April 1988 through March 2006, 41 patients with prosthetic valve endocarditis (PVE) complicated by root abscess and/or periprosthetic leak, underwent fresh allograft aortic valve and root replacement. There were 37 males (90.0%) and the mean age was 51.5±13.74 years. NYHA functional class was 2.97±0.1. Thirty-five patients (85.4%) had a mechanical prosthesis and in 11 (26.8%) the PVE was recent (<3 months). Ten patients (24.4%) underwent emergency valve replacement and 4 (10.0%) presented CRF. The end point was patient's death or allograft failure (mean 54.3; 2–166 months). Results: There were 2 hospital deaths (4.9%), one caused by low cardiac output as a consequence of AMI and the other by brain stroke. Five patients needed inotropes for more than 24 h, one of whom required IABP. Nine patients had transient ARF (21.9%). Three patients (7.3%) needed pacemaker for AV block. Late mortality was 8 patients (21.6%). Two died of cardiac reasons, 4 of non-cardiac reasons (stroke-1; acute colecystitis-1; traffic accident-2) and 2 unknown. Two patients needed reoperation due to allograft failure (61 and 82 months). In no case was there evidence of recurrence of endocarditis during the follow-up. The 10-year survival was 79±7.4%. Conclusions: Allograft aortic root replacement in prosthetic endocarditis complicated by abscess and/or paraprosthetic leak is safe, has low morbidity and mortality and, in this series, no infection recurrence. In our experience these results were superior to those obtained with other valvar substitutes.
Brigham and Womens Ho spital, Boston, USA Objectives: Re-operative aortic valve surgery after prior CABG is reported to have increased operative mortality and morbidity. We report our experience with minimally invasive re-operative aortic valve replacement (Reop MI-AVR) after prior CABG. Methods: 896 patients underwent minimally invasive AVR from 1996 to 200 5 at our centre. 114 patients had previous cardiac surgery and 78 of these had a prior CABG. There were 57 males and 21 females with ages between 43 and 93 (mean 75.9). 56.4% were in NYHA class III or IV. Our operative strategy includes peripheral cannulation for cardiopulmonary bypass, moderate to deep systemic hypothermia (20–28 o C), myocardial protection with antegrade and retrograde blood cardioplegia and systemic hyperkalaemia. The grafts remained undisturbed throughout. The outcomes were analysed from our database and compared with the predicted STS data. Statistics were performed using SPSS 13.0 (Chicago, IL). Results: The operative mortality rate was 1/78 (1.28%) versus the predicted STS operative mortality of 8.05% (P<0.001). Perioperative MI (enzyme blood levels), re-operation for bleeding and CVA rates were 7 (8.9%), 1 (1.2%) and 0 (0%), respectively. No patient sustained a graft injury during re-entry or upper mediastinal dissection. Conclusions: Re-operative minimally invasive AVR after previous CABG is safe and efficacious. Our operative strategy to leave the grafts undisturbed during re-operative surgery yields better outcomes and is an excellent procedure of choice for re-operative aortic valve disease after prior CABG.
092 - O WHAT IS THE IMPACT OF HEART DONORS WITH SUBSTANCE ABUSE ON SHORT- AND LONG-TERM OUTCOMES FOLLOWING HEART TRANSPLANTATION? K.J. Shea, A. Sopko, K. Ludrosky, K. Hoercher, N.G. Smedira, D.O. Taylor, R.C. Starling, G.V. Gonzalez-Stawinski Cleveland Clinic, Cleveland, USA Objectives: To determine the short- and long-term outcomes of heart transplant recipients receiving hearts from donor with a history of substance abuse. Methods: Retrospective chart review was performed of heart recipients. Charts provided demographics, mechanisms of donor death, and history of substance abuse. Additionally, charts were quarried for post-operative echocardiography and coronary angiogram results, serologic tests, and survival.
Results: Between January 1997 and December 2005, 689 heart transplants were performed, of these 150 (21.8%) had a history of substance abuse. The mean donor age was 34.5 years (16–62). Most common cause of death was traumatic head injury 89 (56.7%). One hundred and fourteen (72.6%) had a history of 1ppd smoking for Conclusions: A history of substance abuse does not influence the overall survival, cardiac function, or risk of TCAD in heart transplantation. Furthermore, the risk of viral transmission is low.
Papworth Hospital, Cambridge, UK Objectives: Cardiac arrest in the organ donor raises concerns about the possibility of ischaemic cardiac damage. We evaluated the outcome of heart transplantation in patients receiving an organ from donors who had suffered a period of cardiac arrest. Methods: Demographics, operative details and outcome data were obtained retrospectively. Actuarial survival was reported using Kaplan Meier analysis and compared with the log rank test. Cox proportional hazards regression was used to model risk adjusted survival. Results: Between January 1st, 1991 and November 1st, 2004, 38 patients were transplanted with hearts from multiorgan donors who were resuscitated after a cardiac arrest. The mean (S.D.) duration of cardiac arrest was 15 (8) min. The interval between donor cardiac arrest and organ excision was 69 (5) h. The 30 day mortality was 2.6% (1/38). In the same interim 566 patients underwent cardiac transplantation with hearts from organ donors without a cardiac arrest. Median time to follow up was 61 months (IQR 15–166). One- and five-year survival comparing the arrest and non-arrest groups was 94.2 vs. 83.6% and 79.8 vs. 74.5%, respectively, P=0.35. Donor cardiac arrest was not an adverse predictor of mortality on multivariate analysis, the adjusted odds ratio was 0.86 (95% CI 0.60-1.25, P=0.42) Conclusions: With careful case selection, there was no evidence that survival after cardiac transplantation was worse following a period of cardiac arrest in the organ donor. A history of cardiac arrest in the organ donor should not exclude an organ from being considered for transplantation.
1German Heart Institute, Berlin, Germany; 2Dominikus Krankenhaus, Berlin, Germany Objectives: The criteria for organ acceptability have been considerably extended and donor grafts with coronary atherosclerosis are among those offered. This study evaluated whether and to what degree pre-existing coronary atherosclerosis may be acceptable. Methods: A total of 1253 consecutive HTx recipients were investigated retrospectively for donor-transmitted coronary atherosclerosis (DCAS). DCAS was defined as focal atherosclerosis with stenosis of >49%. Inclusion criteria were absence of pre-HTx angiogram but performance of angiogram or autopsy within 6 months after HTx. Results: Eighty-five out of 1253 (6.8%) cases were excluded, since angiography was not performed within 6 months (n=45) or during donor screening (n=40). In 1086 patients no DCAS was found (NDCAS group) and in 82 patients (7%) DCAS was diagnosed by angiography (n=49) or autopsy (n=33). Single-vessel DCAS was found in 53/82 patients (DCAS1 group) and double- or triple-vessel DCAS in 26/82 patients (DCAS2/3 group). Three of the 82 patients with DCAS were excluded since the autopsy report was unclear regarding degree of DCAS. Early after HTx the instantaneous risk of death in the NDCAS and DCAS1 groups was 0.05 vs. 0.07 (P<0.05) whereas in the DCAS2/3 group it was 0.42 (P>0.05). However, beyond the first year the annual decrease in all groups was comparable (5.4%/year; 4.0%/year; 4.5%/year; all P>0.05). Conclusions: Donor grafts with single-vessel CAS may be accepted as marginal hearts; however, revascularisation (CABG, PTCA) should be considered. Grafts with diffuse CAS have a serious risk for early graft failure. Beyond the first year the outcome of healthy grafts and grafts with DCAS are comparable.
Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany Objectives: Because of the current critical shortage of cardiac allograft donors the decision to offer repeat heart transplantation must be carefully considered. Methods: Since 1983 a total of 807 heart transplantations have been performed at our institution. Among them 43 patients received retransplantation, 18 patients after acute graft failure (Group A) and 22 after chronic graft failure (Group B). 37 patients were male and 6 were female. Mean age was 49±2 years (range 13–68 years). Results: 30-day mortality was 44% in Group A vs. 0% in Group B (n<0.05). Overall survival after cardiac retransplantations was 52±8% at 1 year, 47±8% at 5 years and 21±8% at 10 years. Survival in Group A was significantly worse compared to Group B (33±1 vs. 91±6% at 1 year, 28±11 vs. 77±9% at 5 years and 21±10 vs. 67±10% at 10 years). Causes of death were acute and chronic rejection, infection and sepsis and other reasons. Conclusions: According to these results we consider retransplantation in chronic graft failure a justified therapeutical option. In contrast, retransplantation in acute graft failure has to be thoroughly evaluated for every individual patient.
West German Heart Centre Essen, Essen, Germany Objectives: Improvement of preservation is still a major research objective in lung transplantation. Effects of PDE-5-inhibitor during procurement are still not clear yet. It was the aim of this study to investigate the effect of Sildenafil on post-transplanted lung function in a porcine model. Methods: In control group lungs were flushed with buffered LPD-solution (I) and compared to LPD-solution with supplementation of 0.15 mg/kg/body wt Sildenafil (II), whereas in a third group 0.15 mg/kg/body wt Sildenafil was administred intravenously 20 min prior to LPD-flushing (III). All grafts were stored for 24 h at 4–6 °C. Haemodynamics and blood gases were monitored until 6 h after reperfusion. Lung tissue was taken for wet/dry assessment. Results: All animals of Groups I and III survived the entire observation period in contrast to 4 animals of Group II which died within 4 h after reperfusion due to severe reperfusion injury. Group II showed a lower mean PAP and a reduced PVR throughout the observation period but did not reach significance due to low number of surviving animals. Group III achieved significantly improved PO2/FiO2 fraction at all timepoints and a significant reduced PVR [434±98 vs. 594±184 dyn*s*cm-5, II vs. I, mean±S.D., P<0.01] at 6 h. Wet/dry ratio was significant higher in Group II throughout the experiment. Conclusions: Sildenafil allows for a better graft function after 24h ischaemia when given prior to standard flushing and preservation. This effect can be explained by a complete/homogenous preservation achieved by selective pulmonal vasodilatation. However, this effect seems to persist when sildenafil remains in the storage solution, leading to severe pulmonary oedema.
Mayo Clinic, Rochester, USA Objectives: Infection is a major cause of mortality in the first year following single lung transplantation, and a risk factor for the development of obliterative bronchilitis, limiting 5-year survival to approximately 45%. Better understanding of the effects of infection on pulmonary allograft vasculature could aid in development of better diagnostic and therapeutic targets. Methods: After single lung transplantation, dogs were immuno suppressed with methylprednisolone acetate, cyclosporine and azathioprine. After 5 days, infection was induced in one group of dogs by endobronchial inoculation of antibiotic resistant Eschericia coli (infection group, n=5); in the second group, the same amount of culture medium without bacteria was flushed into the bronchus (control group, n=4). All animals were medicated under the same drug protocol. On post-operative day 8, all animals were sacrificed; the pulmonary arteries were recovered, cut into rings and suspended for pharmacological characterisation in organ chambers. Results: Contractions to phenylephrine and angiotensin-1, but not endothelin-1were reduced in rings with but not without endothelium from pulmonary arteries from infected lungs (P<0.05). Inhibition of nitric oxide synthase with L-NMMA restored these contractions. Endothelium-dependent relaxations to adenosine diphosphate and calcium ionophore, which stimulate release of endothelium-derived nitric oxide by a receptor and non-receptor mediated process, respectively, were not different between groups. Relaxations to nitric oxide also were not different between groups. Conclusions: These results suggest that infection selectively affects contractions of the allograft pulmonary vasculature and that those effects are mediated in part by endothelium-derived nitric oxide.
Medical University of Vienna, Vienna, Austria Objectives: Acute cardiac allograft rejection is associated with TGF-ß and bFGF upregulation. These cytokines modulate MMP-1 expression. This study analyzed MMP-1 serum concentrations in relation to acute allograft rejection in heart transplant recipients. Methods: Endomyocardial biopsies and serum samples were obtained from 77 consecutive recipients at 1, 2, 3, 4, 6, 8, 12 and 24 weeks post-transplant. Immunosuppression comprised cyclosporine A (CyA; n=46) or tacrolimus (TAC; n=20) with mycophenolate mofetil and steroids, or CyA with everolimus (EVL) and steroids (n=11). Rejection (defined histologically according to ISHLT-guidelines) and infection episodes were assessed. MMP-1 serum concentrations were measured using ELISA in patients and 20 controls.
Results: Control MMP-1 serum concentrations were 17.7±5.2 ng/ml. Rejection was diagnosed in 75 out of 455 biopsies (grade 1A/B: n=15/42; grade 2: n=6; grade 3A/B: n=8/4). All rejection episodes occurred in patients (n=34) with MMP-1 serum concentrations=5 ng/ml during the first two weeks post-transplant. Patients with initial MMP-1 concentrations Conclusions: Serum MMP-1 is a sensitive, specific, and easily measurable marker of efficient immunosuppression that does not correlate with infection episodes. MMP-1 serum concentrations =4 ng/ml predict rejection-free outcome after cardiac transplantation.
1Department of Cardiac Surgery, Heidelberg, Germany; 2Department of Cardiology, Heidelberg, Germany; 3Department of Haematology and Oncology, Heidelberg, Germany; 4Department of Pathology, Heidelberg, Germany Objectives: Cardiac amyloidosis (CA) is associated with a poor prognosis and a survival rate of less than 30% after two years of clinical manifestation. Considered as a semi-malignant disease, CA is often a contraindication for HTx. However, based on the type of CA, there are excellent treatment options in combination with HTx. For AL-amyloidosis, chemotherapy and stem cell transplantation, for TTR-amyloidosis, in which the liver is the source of the pathologic protein, liver transplantation is therapy of choice after HTx. Methods: Until 2005 more than 56 patients with ALL and more than 20 patients with TTR amyloidosis have been investigated in our centre. Fourteen patients showed signs of end stage heart failure. Results: Four patients died while less than one month on the heart waiting list. Five patients with AL (mean age 41.8 years) and 6 patients with TTR-amyloidosis (mean age 42.6 years) were successfully transplanted with a one year survival of 89%. One patient died 8 months after HTx due to infection. Three AL-patients received chemotherapy and PBSCT and 2 TTR-patients were liver transplanted. One AL patient showed complete remission of amyloidosis after one year. Conclusions: Cardiac amyloidosis is a potentially curative disease in combination of HTx with either chemotherapy and PBSCT or LTx depending of the type of the amyloidosis. Due to the natural course of the disease, urgent Htx after cardiac manifestation is mandatory. With this approach, excellent survival rates and even remission of the underlying disease is possible.
100 - O IMPACT OF LEFT ATRIAL (LA) VOLUME REDUCTION ON THE RESTORATION OF BOOSTER FUNCTION OF ENLARGED LA AFTER THE COX-MAZE PROCEDURE: ASSESSMENT BY MAGNETIC RESONANCE IMAGING (MRI) A. Marui, T. Nishina, K. Tambara, Y. Saji, T. Shimamoto, T. Ikeda, M. Komeda Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan Objectives: The Cox-Maze procedure concomitant with LA volume reduction (VR) is reported to facilitate sinus rhythm (SR) recovery even in patients with refractory atrial fibrillation (AF) with enlarged LA. However, it is unknown whether the procedures can also restore effective booster function of the enlarged LA with over-stretched myocardium.
Methods: The Cox-Maze procedure in association with mitral valve surgery was performed to 38 AF patients with enlarged LA (diameter Results: Preoperative maximum LA volume (MaxLAV, ml) and booster function (emptying fraction: LAEF,%) assessed by cine-MRI were not significantly different between the VR and the control (383±132 vs. 337±111 ml and 8.9±3.8% vs. 10.8±4.0%, respectively). At a follow-up time of 13.1±7.9 months, SR recovery rate was better (90% vs. 73%, P<0.05) and MaxLAV was drastically smaller (154±48 vs. 311±87 ml; P<0.01) in the VR than those in the control. Most importantly, among the patients with SR recovery, LAEF improved only in the VR (21.6±5.9% at follow-up vs. 8.9±3.8% at preoperation, P<0.05). Conclusions: The Cox-Maze procedure concomitant with the LA-VR restored LA booster function of the enlarged LA; however, the Cox-Maze procedure alone did not restore LA function in spite of SR recovery. LA-VR may be desirable to improve atrial function as well as SR recovery rate to the refractory AF with enlarged LA.
Seoul National University Hospital, Seoul, Korea (South) Objectives: We evaluated the long-term results of the Cox-Maze III procedure (CM-III) for chronic atrial fibrillation (AF) associated with rheumatic mitral valve (MV) disease. Methods: We retrospectively analysed 127 patients who underwent the CM-III combined with a rheumatic MV procedure between 1994 and 2004. In-hospital mortalities were excluded from the study. Results: There were 4 late deaths and the mean follow-up duration was 6.3±3.1 years (0.8–11.2 years). Normal sinus rhythm was restored in 88.2% (112/127) after the CM-III. Right atrial contractility was demonstrable in 100% and left atrial contractility in 72.4% (92/127) of the patients. Fifteen patients remained in AF. Permanent pacemakers were implanted in 6 patients during the follow-up. Late recurrence of AF developed in 34/112 patients at 43±27 months postoperatively, and sinus conversion restored in 29/34 patients by addition of antiarrhythmic medications. Freedom from AF recurrence was 88% at 1 year, 75% at 3 years, 67% at 5 years, and 58% at 7 years postoperatively (P<0.05). Risk factors for AF treatment failure were longer duration of AF (>60 months; P<0.001), elderly patients (P=0.03), and tricuspid regurgitation (>moderate degree; P=0.006). Risk factors for late AF recurrence were longer duration of AF (>60 months; P=0.004), increased left atrial dimension (P=0.009), and late development of tricuspid regurgitation(>moderate degree; P=0.016). Conclusions: The CM-III for chronic AF associated with rheumatic MV disease demonstrated a progressively decreased sinus conversion rate during the follow-up period. Early surgical therapy for patients with chronic AF, and correction of tricuspid regurgitation and left atrial reduction at time of surgery may increase the long-term success rate.
1Cardiac Surgery Unit, Magna Graecia University, Catanzaro, Italy; 2Cardiovascular and Diseases Unit, Magna Graecia University, Catanzaro, Italy Objectives: Clinical, echocardiographic results and determinants of atrial fibrillation (AF) recurrence following AF ablation during mitral valve surgery (AFAMVS) were evaluated. Methods: 52 patients undergoing radiofrequency AFAMVS between January 2003 and December 2005, underwent serial echocardiographies with Tissue Doppler Imaging to assess atrio-ventricular function. Recurrence of AF, hospital readmission, episodes of congestive heart failure (CHF) were recorded. Predictors for AF-recurrence were evaluated. Results: At 29.5±8.6 months of follow-up (100% complete), 78.8% patients were in sinus rhythm (SR). Freedom from AF-recurrence was 64.6±0.76%, from hospital readmission 88.9±0.47%, from CHF 91.6±0.63%. SR-patients demonstrated better freedom from hospital readmission (97.4% vs. 60.6%; P=0.0003) and from CHF (100% vs. 72.7%; P=0.008) during follow-up. At follow-up SR-patients demonstrated left atrial (preoperative 5.8±0.8 cm vs. follow-up 5.1±0.9; P=0.013) and ventricular reverse remodelling (preoperative LVDd 5.7±1.1 cm vs. follow-up 5.2±1.1; P=0.048 – preoperative LVDs 4.0±1.4 vs. follow-up 3.6±1.1; P=0.036). E/A ratio was normal in 73.1% (92.7% of SR-patients). TDI at the level of the left lateral annulus showed an improved left ventricular systole (Sm), and diastole (Em, E/Em) of SR-patients, compared with AF-patients (Sm 9.40±1.74 vs. 7.72±1.5, P=0.0001; Em: 10.45±1.98 vs. 7.68±0.72, P=0.001; E/Em: 0.07±0.02 vs. 0.10±0.04, P=0.0001). Large preoperative atrial diameter (OR=5.81; P=0.002), preoperative NYHA-IV (OR=3.55; P=0.001), high diuretics at discharge (OR=1.27; P=0.03), tricuspid insufficiency at follow-up (OR=2.31; P=0.02) were independent predictors of AF-recurrence. Conclusions: Radiofrequency AFAMVS achieves 78.8% of SR recovery. Maintenance of SR improves clinic, haemodynamic and echocardiographic endpoints. Pre- and post-operative cardiac failure is the main determinant of AF-recurrence.
Department of Cardiac Surgery, Glenfield Hospital University, Hospitals of Leicester, Leicester, UK; 1Department of Cardiology, Glenfield Hospital University, Hospitals of Leicester, Leicester, UK Objectives: There is conflicting evidence with regard to the impact of preoperative atrial fibrillation (AF) on the post mitral valve (MV) repair early and late survival. Methods: A total of 349 consecutive patients undergoing various MV repair procedures (supported with a ring annuloplasty) for degenerative MR between 1997 and 2003 were studied. Preoperatively, 152 (44%) of these patients were in AF and 197 (56%) patients were in sinus rhythm (SR). The clinical features and the early and late survival in these two cohorts of patients were compared. Results: The patients in the AF group were older (mean age 66 vs. 62 years, P=0.01), had a higher mean NYHA class score (2.8 vs. 2.5, P=0.04) and were more likely to have impaired left ventricular function (60% vs. 40%, P<0.0001). Nevertheless, the AF patients were less likely to undergo urgent or emergency procedures (16% vs. 32%, P=0.04). A similar proportion of patients in the two groups had concomitant cardiac surgical procedures (21% vs. 25%, P=0.8) with comparable ischemic and cardiopulmonary bypass times. Operative mortality was 3.9% in the AF group vs. 0.5% in the SR group (P=0.04), whereas Kaplan-Meier survival at 5 years was 84 vs. 94% (P=0.009). On multivariate analysis, AF (P=0.03) and impaired LV function (P=0.02) were significant adverse predictors of survival. Conclusions: Preoperative AF in patients undergoing MV repair for degenerative MR, has a major negative impact on the early and late survival.
German Heart Institute Berlin, Berlin, Germany Objectives: Maze procedure in combination with surgery for organic heart disease effectively eliminates chronic atrial fibrillation. However, it is not clearly defined how many patients will still remain in chronic atrial fibrillation following alone surgery for organic heart disease without maze procedure. The aim of this study was to identify whether alone surgery for organic heart disease might eliminate chronic atrial fibrillation. Methods: One hundred and sixty five consecutive patients (age, 30–80 years) with preoperative chronic atrial fibrillation underwent surgery for organic heart disease with modified maze procedure [n=48 patients (isolated valve procedures or CABG, n=27 patients; combined procedures, n=21 patients)] or without modified maze procedure [n=117 patients (isolated valve procedures or CABG, n=90 patients, combined surgery, n=22 patients]. Results: Freedom from atrial fibrillation in non-maze group vs. maze was 98% (114/117 patients) vs. 100% intraoperatively, 38% (44/117 patients) vs. 25% (12/48 patients) at 1 week after surgery, 16% (18/227 patients) vs. 59% (16/27 patients) at 1 month, 6% (7/115 patients) vs. 64% (16/25 patients) at 3 months and 3% (3/114 patients) vs. 92% (12/13 patients) 6 months postoperatively. Conclusions: If the maze procedure was not performed during surgery for organic heart disease, atrial fibrillation recurred in almost all patients during the late follow-up. Maze procedure should be added to surgery for organic heart disease in patients with chronic atrial fibrillation.
1Seoul Veterans Hospital, Seoul, Korea (South); 2Korea Research Institute of Standards and Science, Daejeon, Korea (South); 3Cungham National University Hospital, Daejeon, Korea (South) Objectives: Map-guided surgery is the best method for treatment of atrial fibrillation, because it minimises unnecessary incisions or procedures. Electrophysiologic (EP) study for mapping is useful, but still time-consuming, difficult to do, unstable and unreliable. Intra-operative mapping with epicardial patch electrode is useful only during the operation; therefore, it is very invasive and useless for follow-up. We propose a totally noninvasive method to detect atrial arrhythmia with a SQUID (superconducting quantum interference device) magnetocardiography system. Methods: To detect weak atrial excitation, we utilised a high sensitive low-Tc 64-channel SQUID MCG system measuring tangential magnetic field components, which is known to be more sensitive to a deeper current source. We measured the MCG signals from three patients with chronic atrial fibrillation. Then, we separated the f wave from the other components by using independent component analysis. The extracted f wave was three-dimensionally localised on the mesh model of a human heart by a sophisticated inverse solution. Results: It is detected that atrial f wave MCG signals from chronic atrial fibrillation patients. We localised the abnormal stimulation source of an atrial arrhythmia non-invasively and visualised the current source distribution corresponding to the atrial excitation successfully on the three-dimensional atrial surface, which was separated from the ventricular excitation. Conclusions: MCG is a totally non-invasive and non-contact method for mapping to detect atrial arrhythmia. The visualisation of atrial current distribution would be a good help for planning AF surgery. However, more technical advances in sensitivity of MCG system and image processing solution are required for more accurate source localisation.
106 - I FONTAN FAILURE: CLINICAL CAUSES AND EXPERIMENTAL HYDRODYNAMIC EVALUATION A. Amodeo1, S. Giannico1, M. Grigioni2, D. Di Carlo1, G. D'avenio2, C. Del Gaudio2, S.P. Sanders1, R. Di Donato1 1Bambino Gesu Hospital, Rome, Italy; 2istituto Superiore Di Sanita, Rome, Italy Objectives: We reviewed our 17-years experience with extracardiac Fontan operation in 250 cases focusing on the causes of failure (take down/death) and to verify by experimental evaluation their hydrodynamic impact. Failure rate was 14% in the first 10 years (115 patients), mostly following extreme indications, and dropped to 4% in the last 7 years (135 patients). Methods: Mechanisms of failure were identified by reviewing postoperative cardiac catheterisations. They were, then, reproduced by in vitro and numerical simulations to verify their hydrodynamic impact on the cavopulmonary pathway. We, therefore, analysed the hydrodynamics: (1) of TCPC in the presence of stenosis of the left or right pulmonary artery; (2) of azygos continuation of the IVC with two surgical options, an extracardiac conduit carrying the hepatic venous blood to the pulmonary arteries and direct anastomosis of the hepatic veins to the azygos vein, respectively. Results: The presence of left pulmonary artery stenosis and the unfavourable arrangement of the cavopulmonary connection in patients with azygos continuation of the IVC were the predominant causes of failure. Stenosis of the left pulmonary artery causes a worse hydrodynamic pattern compared to stenosis of the right pulmonary artery. In presence of azygos continuation of the IVC an inferior caval conduit anastomosed to the cavopulmonary tree has energetic loss of 50% compared to the direct anastomosis of the hepatic veins to the azygos vein. Conclusions: These experimental studies confirm our clinical appraisal that (1) a stenoses of the left pulmonary artery in Fontan patients causes a worse hydrodynamic pattern and (2) in patients with azygos continuation of IVC, the direct connection of the hepatic veins to the azygos vein is a much more efficient arrangement.
1Sejong General Hospital, Bucheon, Korea (South); 2Seoul National University Hospital, Seoul, Korea (South) Objectives: Extracardiac conduit Fontan procedure has some theoretical advantages, but lack of growth potential of the artificial conduit is the main concern. This study investigated the change and status of artificial conduits used in extracardiac conduit Fontan procedure. Methods: Between 1996 and 2005, 154 patients underwent extracardiac conduit Fontan procedure using Gore-Tex conduit. We measured the internal diameter of the conduit and IVC angiographically in the 46 patients who underwent cardiac catheterisation and angiography. Results: Mean follow-up duration was 36.1±19.7 months. The conduit diameter used was 16 mm (n=10), 18 mm (n=16), 20 mm (n=14), 22 mm (n=4), and 24 mm (n=2). The mean anteroposterior-to-lateral conduit diameter ratio was 1.27±0.19. The mean conduit-to-IVC cross-sectional area ratio was 1.25±0.33. According to the conduit size used, this ratio was 1.03±0.17 for 16-mm conduits, 1.33±0.37 for 18-mm, 1.33±0.36 for 20-mm, 1.28±0.26 for 22-mm, and 1.05±0.06 for 24-mm conduits (P<0.05, 16 mm vs.18 mm and 20 mm). The mean percentage decrease of the conduit cross-sectional area was 14.3±8.5%, and this did not differ significantly according to the conduit size (P=0.82). Follow-up duration and the percentage decrease of the conduit cross-sectional area did not show significant correlation (r=0.22, P=0.14). Conclusions: During follow-up, the conduit cross-sectional area decreased by 14%, and this did not differ according to the conduit size used. The extent of decrease of the conduit cross-sectional area remained stable irrespective of the follow-up duration. Careful follow-up for 16-mm conduits is warranted because of possible conduit stenosis relative to patients’ somatic growth.
Tokyo Womens Medical University, Tokyo, Japan Objectives: Some patients with double discordance may be eligible for double switch operation (DSO). The aim of this study is to clarify the outcome of pulmonary artery banding (PAB) for DSO candidates who require LV training. Methods: The records of patients who had undergone PAB for LV training prior to DSO from 1989 to 2006 were reviewed. Follow-up range was from 2 months to 14 years. Results: Thirteen patients underwent PAB as left ventricular training for DSO. Five had a small ventricular septal defect (VSD), one had undergone VSD closure in other hospital and seven had intact ventricular septum. Initial PAB was done between 1.3 and 16 years of age. Seven attained DSO after initial or second PAB. Five attained DSO after initial PAB and two achieved DSO after second PAB. Six patients could not attain DSO after PAB, then underwent PA debanding because of severe heart failure. Three underwent conventional repair (CR), two are awaiting next intervention and one died 4 months after PAB. Early survival in those who attained DSO was 6/7. 2/3 in those who underwent CR died. Early survivors were free from re-operation in our follow- up period. All survivors after DSO or CR are currently in NYHA class I. Conclusions: Despite demanding condition, the outcome of DSO subsequent to PAB is satisfactory. However, in those who did not obtain adequate LV function after PAB, prognosis was very poor even though CR was performed. Careful consideration whether they should undergo second PAB or not is important.
Birmingham Children's Hospital, Birmingham, UK Objectives: Some anatomical subgroups of hypoplastic left heart syndrome (HLHS) have normal sized ascending aorta and arch. An alternative to the Norwood I procedure in these patients is creation of an aorto-pulmonary (AP) window and distal pulmonary artery band (PAB). We reviewed our experience with this technique and compared its outcome to the Norwood procedure for HLHS. Methods: Between 1992 and 2005, we identified 13 patients treated with AP window/ PAB and compared them to 333 Stage I Norwood patients. The band was tied over a 4-mm dilator placed in the main PA. Results: There were seven early deaths (54%) and one conversion to a Norwood circulation due to persistent low diastolic pressure. Aortic cross clamp time were significantly lower in the AP window group compared to the Norwood population (median time of 35 and 55 min, respectively P<0.01) as well as circulatory arrest times (16 and 51 min, respectively (P<0.01)). No differences in arterial saturations and systolic blood pressure existed between the groups but postoperative diastolic blood pressure in the AP window group was 27±10 mmHg compared to 42±8 mmHg in the Norwood group (P<0.01). Diastolic flow reversal was seen in the descending aorta. AP window survival was significantly worse than the Norwood procedure (mortality 29%) (P=0.01). Conclusions: Despite shorter ischaemic times, the AP window/PAB has a poor outcome compared to the Norwood procedure for HLHS. The resultant low diastolic pressure causes diastolic flow reversal and may result in coronary steal. We recommend the Norwood procedure for these subtypes of HLHS.
Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Tsu, Japan Objectives: We report our experience of performing bilateral pulmonary artery banding for stage I palliation for hypoplastic left heart syndrome. Methods: Since 2002, bilateral pulmonary artery banding for stage I palliation was performed for seven hypoplastic left heart syndrome patients; 4 diagnosed with aortic atresia/mitral atresia and 3 with aortic stenosis/mitral stenosis. Two patients had an associated chromosome anomaly and one had an intact atrial septum and left atrium-innominate vein communication. Results: Balloon atrial septostomy was performed in four patients before stage I palliation. Bilateral pulmonary artery banding (right or left circumference: 10 to 14) was performed at 7–19 days of age and 2.6–3.5 kg weight. Systemic flow was maintained in 5 patients by prostaglandin E1 infusion, and by a main pulmonary artery to the descending aorta shunt in 2. Before stage II palliation, balloon atrial septostomy was performed in 4 patients, and an atrial septal defect enlargement or creation was in one patient each. For all 7 patients, Norwood+bidirectional Glenn shunt was performed in stage II palliation (3–9 months of age, 2.9–4.7 kg weight). Two early deaths occurred due to postoperative pulmonary hypertension crisis after stage II. The other 5 patients are alive (5/7: 71%), 2 with a status of Fontan completion. In the four patients without a chromosome anomaly, there are no problems of mental retardation. Conclusions: Bilateral pulmonary artery banding strategy may offer a staged surgical option for hypoplastic left heart syndrome.
Fu Wai Heart Hospital, Beijing, China Objectives: We reported an open-chest interventional beating heart surgery which integrated the device and surgical approach to treat congenital heart disease. Methods: During the past year, 28 patients received open-chest interventional cardiac surgery. Group 1 included pulmonary atresia with intact ventricular septum in neonate (n=5) and severe pulmonary stenosis in infants (n=5); Group 2 included ASD in child less than 2 years (n=11) (included 1 case associated with partial anomalous pulmonary venous connection), muscular VSD (n=3) and adult ASD with coronary disease (n=4). All the procedures were guided by the echocardiography. The pulmonary valve was perforated and balloon was inserted by perventricular approach. The modified Blalock-Taussig shunt was added and PDA was ligated after successful valvuloplasty for the pulmonary atresia. ASD and VSD were closed with the occluder by peratrial or perventricular approach, and then the associated disease was treated separately including off-pump CABG, relocation of anomalous coronary artery or right pulmonary venous. Results: Average time of valvuloplasty was 23 min. The closure time of ASD and VSD was 11 and 30 min average. Only one infant died from pneumonia after successful VSD occlusions. Other patients discharged eventually. During follow-up (1–12 months), no devices-related complications were observed in Group 2. The neonates with pulmonary atresia regained the growth of RV and obvious pulmonary restenosis was observed only in one infant. Conclusions: There were no vascular-access and weight limit to use the devices while opening the chest. The extensive use of intraoperative device and real-time imaging outfits offered a novel one-stop platform for the cardiac surgeon to avoid cardiopulmonary bypass and thus could improve the outcomes of the management of congenital heart disease.
1Seoul National University Children Hospital, Seoul, Korea (South); 2Sejong General Hospital, Bucheon, Korea (South) Objectives: We survey if the regional cerebral and myocardial perfusion may eliminate neurological complications or myocardial injury following deep hypothermic circulatory arrest during repair of aortic arch anomalies, and evaluate our current approach utilising extended end-to-side anastomosis without prosthetic material to enlarge all areas of aortic arch hypoplasia. Methods: From March 2000 to December 2004, 60 neonates or infants with aortic arch anomaly underwent one stage biventricular repair with continuous cerebral perfusion and a nonworking beating heart by the dual perfusion technique into the innominate artery and aortic root. Preoperative diagnosis of the arch anomaly consisted of aortic coarctation (n=47), and interrupted aortic arch (n=12). Combined anomalies were VSD (n=49), truncus arteriosus (n=2), atrioventricular septal defect (n=2), DORV (n=1), TAPVR (n=1), and PAPVR (n=1). Results: The regional perfusion time of brain was 28±10 min. There was neither operative mortality nor late mortality during 32.6±16.1 months of follow-up. Postoperative low cardiac output was present in 4 patients (6.7%). Neurologic complication was noted in one patient (1.7%) who developed transient chorea, but completely recovered. One developed left main bronchial compression necessitating aortopexy. There was neither reoperation associated with arch anomaly, nor recoarctation during follow-up. Conclusions: One-stage total arch repair using our regional perfusion technique is the excellent method that may minimise the neurologic and myocardial complication without mortality. Our surgical strategy for arch anomaly has a low rate of residual and recurrent coarctation when performed in neonates and infants.
Department of Cardiac Surgery and Paediatric Cardiology, University Hospital Gasthuisberg, Leuven, Belgium Objectives: Over recent years balloon dilation (BD) replaced surgical valvotomy (V) as first-line treatment for congenital aortic valve stenosis (AS). We hypothesised that V may lead to a higher procedural mortality but will result in a longer lasting effect. Methods: We analysed AS in children under 1 year, treated in our centre between 1964 and 2004. Factors influencing survival and re-intervention free survival were tested, as evolution of aortic insufficiency (AI) and ventricular function. Results: Sixty-two children with AS have undergone either V (n=29) or BD (n=33) at a median age of 39 days [0–364]. Follow-up was 7.1 years [0–35]. Survival at 10 years was 80%, with no evidence for a difference in survival between V and BD (P=0.7). No risk factors were identified that influenced overall survival. Re-intervention for AS was needed in 25 children (V=12; BD=13) after an interval of 3.3 years [0–23]. There was no evidence for a difference in re-intervention free survival between V and BD (P=0.38). Age at time of intervention was a significant risk factor for re-intervention free survival (P<0.01; Hazard ratio 0.91). We found no difference in evolution of AI (P=0.98) and fraction of shortening (P=0.75) after V or BD. Conclusions: BD and V are effective treatment options for AS. Survival was not influenced by the type of first intervention for AS. Re-intervention is common but did not affect survival. The only predictor for re-intervention free survival was age at time of intervention. There is no difference in evolution of AI or fraction of shortening.
Dipartimento Medico Chirurgico di Cardiochirurgia e Cardiologia Pediatrica DMCCP, Ospedale Pediatrico Bambino Gesu, Rome, Vatican City State Objectives: Evaluate the impact of genetic syndromes on surgical outcome of conotruncal heart defects in infancy. Methods: Retrospective review of 787 consecutive patients (median age 5.1 months), who underwent primary or staged repair of conotruncal heart defects between January 1995 and December 2005, including tetralogy of Fallot, double outlet right ventricle, pulmonary atresia-VSD, interrupted aortic arch and truncus arteriosus. Total follow-up was 3055 patient years (mean 47 months) and was 99% complete and updated. Results: Genetic syndromes were documented in 221 patients (28.1%), including del22q11 (72), trisomy 21 (28), VACTERL (35) and others (86). Mean ICU stay was 9.5±2.4 days in syndromic patients and 4.9±1.1 days for non-syndromic patients (P=0.017). Actuarial survival at 10.4 years was 90.1±2.3% in non-syndromic patients and 74.3±4.2% in syndromic patients (P=0.0009). Ten-year survival was 81.1±2.1% for del22q11 patients, 96.3±3.6% for Down's patients, 63.6±14.5% for VACTERL patients and 70.5±5.3% for patients with other genetic syndromes (P=0.022). Freedom from reintervention was 81.7±1.8% at 10.4 years in non-syndromic patients and 64.7±7.2% in syndromic patients (P=0.0047). Presence of genetic syndrome other than trisomy 21 (P=0.017) was an independent predictor of mortality by Cox proportional hazard. Del22q11 was identified as a risk factor for hospital mortality in patients with interrupted aortic arch and pulmonary atresia-VSD (odds ratio 2.4, P=0.03). Conclusions: Genetic syndromes other than trisomy 21 adversely affect the surgical outcome of conotruncal heart defects. Del22q11 may influence surgical results in children with pulmonary atresia-VSD or interrupted aortic arch. Mid-term freedom from reinterventions in syndromic patients is lower than that observed in non-syndromic children.
Cardiothoracic Surgery, Cologne, Germany Objectives: The Risk Adjusted Congenital Heart Surgery (RACHS-1) system and the Aristotle Score were developed to compare outcomes of congenital cardiac surgical patients. Both scoring systems have not been validated independently. Methods: All consecutive patients who underwent congenital heart surgery at our institution from January 2003 to December 2005 (454 procedures in 374 patients) were included in the study. The Aristotle score was calculated in the basic (ABS) and in the comprehensive version (CAS) as well. Calibration was assessed with the Hosmer-Lemeshow (HL) goodness-of-fit test and discrimination with receiver operating characteristic (ROC) curves. Results: Mean age was 3.8±5.2 years (range: 1 day–17.9 years), and 39% were female. 30-day mortality rate was 5.7% (26 patients), hospital mortality was 8.1% (37 patients). Mean values for RACHS-1 were 2.5±1.2, and 6.6±2.9 for ABS and 8.2±3.6 for the CAS. Calibration was good for all scores with HL-values of 2.8 (P=0.90) for the ABS, 8.2 (P=0.26) for the CAS, and 2.2 (P=0.34) for the RACHS-1. Discrimination was better for the RACHS-1 with areas under the ROC-curve of 0.76, in comparison to ABS (0.73) and CAS (0.72) scores. Conclusions: The ability to predict hospital mortality with the two scoring systems was moderate. The comprehensive Aristotle score is very time consuming, but fails to predict mortality better than Aristotle basic score. Improvements in score discrimination with larger cohorts remain necessary.
116 - I MEASURED FEV1 IN THE FIRST POSTOPERATIVE DAY, AND NOT PPOFEV1, IS THE BEST PREDICTOR OF CARDIO-RESPIRATORY MORBIDITY AFTER LUNG RESECTION G. Varela1, A. Brunelli2, G. Rocco3, N. Novoa1, M. Refai2, M.F. Jiménez1, M. Salati2, T. Gatani3 1Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain; 2Unit of Thoracic Surgery, Umberto I Regional Hospital, Ancona, Italy; 3Divison of Thoracic Surgery, National Cancer Institute, Naples, Italy Objectives: ppoFEV1% is frequently quoted as an accurate predictor of cardio-respiratory morbidity after lung resection but its correlation with true FEV1% in the immediate days after surgery when most cardio-respiratory complications are developed has not been published. The null hypothesis in this study is that ppoFEV1% keeps its predictive value when first postoperative day FEV1 is introduced in the model. Methods: Prospective, multicentric, observational study on 198 consecutive lung resection cases. Independent variables: age, preoperative FEV1%, ppoFEV1%, co-morbidity, surgical approach (VATS/muscle-sparing thoracotomy), type of analgesia (epidural/intravenous), FEV1% in the first postoperative day (before any complication). Dependent variable: occurrence of any cardio-respiratory complication, previously defined. Using classification and regression trees (CART) analysis a predictive model was constructed introducing all independent variables. Separate learning and testing cases were selected at random and a bootstrap set of 100 trees were created to investigate the accuracy of the prediction. Results: Postoperative morbidity was 19.7% (39 cases). First postoperative day FEV1% was the most relevant variable (relative importance 100%, FEV1% cut point: 37.4) followed by, patient age, BMI and ppoFEV1 (relative importance 64.9%, 53.4% and 52%, respectively; patient age cut point: 74.5 years; BMI, 24.3, ppoFEV1, 46%). Bootstrap set of trees had an overall accuracy of 63%, but only 13% in complicated subset of the cases. Conclusions: ppoFEV1% looses its predictive value when FEV1% in the first postoperative day is introduced in the model. Development of a predictive equation for first day FEV1 is warranted and clinical importance of this predicted measure should be investigated in prospective trials.
1Leiden University Medical Centre, Department of Cardiothoracic Surgery, Leiden, Netherlands; 2Leiden University Medical Centre, Department of Pulmonology, Leiden, Netherlands Objectives: Evaluation of long-term outcome of diaphragm plication in patients with single-sided or double-sided diaphragm paralysis. Methods: Between December 1996 and January 2006, 22 consecutive patients underwent diaphragm plication. Before surgery spirometry in both seated and supine positions and a Baseline Dyspnea Index were assessed. The uncut diaphragm was plicated as tight as possible in antero-posterior and lateral direction with parallel U-stitches starting at the hiatus. Redundant tissue was brought down with a running suture for reinforcement. Patients with a follow-up exceeding 1 year (n=17) were invited for repeat spirometry and assessment of changes in dyspnea using the Transition Dyspnea Index (TDI). Results: Follow-up was complete in 16 patients (94%). Mean follow-up was 4.9 years (range 1.2–8.7). All spirometry variables showed significant improvement. Mean vital capacity (VC) in seated position improved from 71% (of predicted value) to 81% (P<0.03), FEV1 in seated position improved from 62% to 71% (P=0.04), FEV1 in supine position from 44% to 66% (P=0.02). Before surgery, the mean decline in FEV1 going from seated to supine position was 35%; at follow-up the decline in FEV1 dropped to 17% (P<0.02). TDI showed remarkable improvement of dyspnea (mean +5.69 points on a scale of –9 to +9), indicating that patients returned to a more or less normal way of life. Conclusions: Diaphragm plication for single-sided or double-sided diaphragm paralysis gives excellent long-term results. Most patients are severely disabled before surgery but can return to a more or less normal way of life afterwards.
Korea Universty Ansan Hospital, Ansan, Korea (South) Objectives: Nuss procedure in adults has always been a technical challenge. The conventional Nuss technique not only has difficulty in elevating the heavy adult chest but has resulted in higher complication rates. The aim of this study is to appraise our novel techniques designed for the correction of adult pectus excavatum. Methods: We operated on 686 pectus excavatum patients using our modified technique from August 1999 to March 2006. Among these patients, 178 adults (age 15 or older) were enrolled in this retrospective study. Key modifications made to overcome the limits of the conventional Nuss procedure in adults include the Compound Bar, which has a central exaggerated convexity, and the Crane Technique, which lifts the depressed sternum prior to passage and rotation of the bar. Results: Data comparison was made between pre-crane (before 2002, n=107) and post-crane (after 2002, n=71) groups. Major complication rates (pre-crane: 11(10.1%) vs. post-crane: 1(1.4%), P=0.021) and repair outcome (excellent) (pre-crane: 97(90.7%) vs. post-crane: 69(98.6%), P=0.033) showed improvements. Comparing post-crane group (n=71) with pediatric group (n=502), there was no difference in major complication rates (pediatric: 16(3.2%) vs. post-crane: 1(1.4%), P=0.408), but repair outcome (excellent) (pediatric: 455(90.6%) vs. post-crane: 69(98.6%), P=0.026) was better in adult group treated with crane technique. Conclusions: The crane technique using the compound bar facilitates chest wall lifting and prevents hinge disruption as well as chest wall or internal organ injuries in the repair of adult pectus excavatum. With this new technique, complication rates and repair outcomes in adults have improved and approximated the pediatric group levels.
Sureyyapasa Thoracic and Cardiovascular Diseases, Teaching and Investigation Hospital, Istanbul, Turkey Objectives: Prolonged air leaks and pleural space problems are not uncommon after lower lobe resections of the lungs. The aim of this study is to search the efficacy of perioperative pneumoperitoneum (PP) in preventing these problems. Methods: Sixty patients who underwent lower lobectomy were randomised in regard to use of PP. Thirty patients were taken into the PP group while standard lower lobectomy without PP was performed in other 30 patients. Air (1000–1500 cc) was delivered through a catheter placed under the diaphragm. (1) Amount of drainage from the chest tubes, (2) duration of chest tube drainage and (3) presence of residual pleural space were compared in two groups. Results: There were no statistically significant difference between both groups for age, sex, side and PFTs and type of resection. The mean duration of chest tube drainage was 3.47±1.04 days in PP group and 4.87±1.43 days in control group (P=0.001). The mean amount of chest drainage was 305.0±76.9 cc in PP group and 488.3±215.2 cc in control group (P=0.001). Pleural space problem was seen in one patient (3.3%) in IPP group and in 8 patients (26.7%) in control group (P=0.026). No complication was seen due to PP method itself. Conclusions: Pneumoperitoneum is a simple, short and safe procedure and it decreases (1) postoperative amount of chest tube drainage, (2) duration of chest tube drainage and (3) the possibility of residual pleural space problem.
Thoracic Surgery Department, Humanitas Gavazzeni, Bergamo, Italy Objectives: Thoracoscopic sympathectomy is the most recommendable treatment for severe palmar hyperhidrosis making it a safe procedure with short hospital stay. The purpose of this study was to prospectively assess changes in patients’ overall quality of life and hyperhidrosis-related symptoms and to suggest standardised rules for both patients’ assessment and surgical management approach so as to define the most suitable minimally invasive surgical technique, reduce the incidence of compensatory sweating and postoperative chest pain. Methods: From May 2003 to February 2006, 189 patients (68 males; 121 females) with hyperhidrosis underwent bilateral thoracoscopic sympathectomy. Preoperatively, 123 patients (65%) reported palmar and axillary hyperhidrosis, 44 (23%) palmar only, 19 (10%) axillary only, 3 (2%) facial only. We selected patients by a randomised method in 2 groups: traditional T2–T4 sympathectomy (Group A) and limited sympathectomy according to site of hyperhidrosis (Group B). Results: The postoperative progress was uneventful and the median length of hospital stay was 1.5 day. The surgical outcomes proved to be successful in 99% in both groups of patients at a median follow-up of 18 months. Significant chest pain occurred in 4% of patients. In Group B we found a significant decrease of mild and severe compensatory hyperhidrosis: 46 vs. 14% and 4 vs. 0%, respectively. Conclusions: Videothoracoscopic sympathectomy is a safe and effective method. The standardisation of both the surgical procedure and the postoperative management makes it possible to reduce complications and reverse effects. Limited sympathectomy reduces the incidence of compensatory hyperhidrosis with the same outcome.
Thoracic Surgery Department, Saint Sophia University Hospital of Pulmonary Diseases, Sofia, Bulgaria Objectives: Empyema thoracis is a common thoracic problem with a multitude of therapeutic options. 60 cases with acute parapneomonic empyema in fibrinopurulent stage were included in a prospective study. Methods: Between 1996 and 2003, a total of 60 cases with acute parapneomonic empyema in fibrinopurulent stage were included in a prospective study. They were randomized into 2 homogenous groups, 30 patients each, who underwent early decortication and debridement either via VATS or conventional thoracotomy. VATS followed an initial tube thoracostomy of empyema cavity in 18 cases and in 12 cases it was performed as an initial procedure. Results: In 2 of VATS group cases (7%) a conversion was carried out because of intraoperative bleeding from artificial diaphragmatic lesion (1) and dense pleural adhesions (1). One patient (3%) from thoracotomy group was also reoperated on for postoperative bleeding, and 2 other patients experienced wound suppuration. Compared to thoracotomy group, VATS group showed a significantly lower ICU stay (1.8±1 vs. 4.1±1.8, P=0.026), lower chest tube duration (5.8±1.1 vs. 9±1.3 days; P=0.03) and lower postoperative hospital days (8.7±0.9 vs. 12.81±1 days; P=0.009). Conclusions: In conclusion, VATS decortication is a useful operative method in carefully selected patients with acute pleural empyema in fibrinopurulent phase and has major advantages compared to decortication via open thoracotomy. Although it has high effectiveness, VATS is not indicated in every acute empyema case and its indiscriminate use may lead to futile operations.
1Thoracic Surgery Unit, University of Novara, Novara, Italy; 2Thoracic Surgery, E Morelli Regional Hospital, Sondalo, Italy Objectives: To evaluate the impact of different pleurodesis procedures (mechanical pleural abrasion versus apical pleurectomy) on postoperative morbidity and late recurrence rate after surgical treatment of Vanderschueren's III stage primary spontaneous pneumothorax. Methods: Between January 1998 and December 2003, 227 consecutive patients (186 male and 41 female, mean age 25 years, range 12–39 years) were submitted to 241 video-assisted thoracoscopic surgery for primary spontaneous pneumothorax. All patients underwent apical lung resection and were randomly assigned to mechanical pleural abrasion in 133 (Group A), and to apical pleurectomy in 108 cases (Group B), respectively. Results: Patients’ characteristics were similar for the two groups. No intra- or postoperative deaths occurred. Morbidity was 13.8% for Group A and 6.7% for Group B. Persistent postoperative air-leak rate was similar for the two groups (4.5%, Group A – 5.5% Group B). Haemothorax was significantly more frequent after apical pleurectomy (n=9/108, 8.3%) than after pleural abrasion (n=3/133, 2.3%) (P<0.05); all patients required muscle-sparing thoracotomy for bleeding control. Mean follow-up was 46 months (range, 18–77). Late recurrence occurred in 5 cases after apical pleurectomy (4.6%), and in 7 after mechanical pleural abrasion (5.2%). Conclusions: Mechanical pleural abrasion associated with video-assisted thoracoscopic surgery is safer than apical pleurectomy in the treatment of primary spontaneous pneumothorax. No differences in late recurrence rate were observed between two procedures.
Sheba Medical Centre, Tel Hashomer, Israel Objectives: In a previous study we have shown that the sequence of vessel interruption (SVI) during lobectomy has no impact on tumour recurrence. The aim of the present study was to determine whether SVI has an impact on intraoperative blood loss. Methods: A non-randomized prospective study including 30 patients undergoing lobectomy for neoplasms. Group A had all lobar arteries ligated before interruption of the lobar vein and Group B had a reverse sequence. Generous exclusion criteria were used, so as to include only patients with straightforward lobectomy, attempting to isolate SVI as the only factor that could affect blood loss. Lobar weight was recorded immediately after lobectomy. All ligatures and staples were removed; blood drained from the lobe, collected and measured and thereafter the lobe was weighed again. Results: Sixteen patients entered Group A and 14 Group B. The groups were similar in age, sex, body surface, histology, prior therapy, stage, surgeon and number of segments resected. The amount of blood drained from the lobe was 31.4±13 and 34.2±14.8 ml in Groups A and B, respectively. The lobar weights before and after blood drainage were 179.9±58.1, 144.3±49.7 g and 208.5±72.2, 167.7±68.5, respectively. The amount of blood divided to the lobar weight was 0.178±0.052 in Group A and 0.177±0.099 in Group B. All of these figures did not differ statistically. No patient required blood transfusion during or after surgery. Conclusions: In straight-forward lobectomy the amount of blood retained in the resected lobe is small. This amount is not affected by the sequence of hilar vessel interruption.
Povisa Hospital, Vigo, Spain Objectives: Accordingly surgeons including those of AO-ASIF school recommend that all metallic implants used for fixation of fractures be removed in due course. Reasons for removal of the implants include the possibility of bone atrophy due to stress shielding by rigid bone plates and screws. Other disadvantages are hypothesised carcinogenic potential, the possibility of corrosion, disturbance in normal growth pattern. Absorbable prostheses are currently used in a variety of bone reconstructions and fixations. Methods: This is a case series of rib fracture fixation using absorbable plates and screws consisting of PLGA 82:18 (LactoSorb(r)) from January 2005 through January 2006. Results: Fifteen patients underwent rib fracture fixation with absorbable plates and screws. Indications included flail chest with failure to wean (10 patients), acute pain with instability (4 patients) and chest wall defect (1 patient). As a rule, only 3 or 4 of the most dislocated and unstable ribs were considered for stabilisation (mean 3–9 plates). With a bone perforator, two or three holes were made at the each tip of the ribs and absorbable plates and the screws were applied to drill holes in the traditional way using tapping and tightening with a screwdriver. All patients with flail chest weaned from mechanical ventilation successfully. All patients with pain and instability reported rapid subjective improvement or resolution and giving up analgesia. The period of follow-up ranged from 9 to 18 months. Conclusions: Absorbable plates produce good clinical results and are an option for rib fracture repair. Four screws fixation at least are required. Further refinements in technique should focus on minimally invasive methods.
Pisa University Hospital, Cardiothoracic Department, Pisa, Italy Objectives: We aimed to investigate if thoracic epidural anaesthesia (TEA) might have a role for primary pneumothorax thoracoscopic treatment. Methods: Twenty four patients were randomly assigned to receive TEA (Group A, 12 patients), and general anaesthesia with one lung ventilation (Group B, 12 patients). General anaesthesia was accomplished with intravenous ipnotic/opioid/relaxant for induction and maintained with halogenated. TEA was performed at T4-T5 level to achieve somatosensory block from T1 to T8 level. A single shot of lidocaine 60 mg, ropivacaine 1% 10 ml and fentanyl 0.1 mg was used. All TEA patients received nebulized lidocaine 2% and O2 through a ventimask before surgery, and light sedation before laying in lateral decubitus. Pre-emptive analgesia was performed in both groups with intravenous ketorolac. Postoperative analgesia was performed with ketorolac on patient's demand in all cases. Global operative time (anaesthetic and surgical time), patient's satisfaction (excellent=4, good=3, satisfactory=2, unsatisfactory=1), postoperative VAS, hospital LOS were recorded in both groups. Results: We found no differences in global operative time, patients’ satisfaction (stated 3 by all the patients) and postoperative pain assessment (VAS=2.5–3 for both groups). Hospital LOS was 48±6 h for the TEA group and 60±7 h for the general anaesthesia group. Conclusions: Our data suggest that TEA for VATS of primary pneumothorax can reduce hospitalisation. No differences were found in analgesia, operative time and pt's satisfaction. TEA should be performed in selected high risk patients (difficult airways management, recurrent bilateral pneumothorax for pulmonary displasia) when general anaesthesia could be contraindicated.
126 - O THE ARTERIAL REVASCULARISATION TRIAL (ART): A RANDOMISED TRIAL COMPARING SURVIVAL FOLLOWING BILATERAL VERSUS SINGLE INTERNAL MAMMARY ARTERY GRAFTING D.P. Taggart1, B. Lees2, M. Flather2, on behalf of the ART. Investigators3 1John Radcliffe Hospital, Oxford, UK; 2Royal Brompton Hospital, London, UK; 3Hospitals, in UK, Australia, Poland, Brazil Objectives: Standard CABG surgery uses a single internal mammary artery (SIMA) and supplemental vein or radial artery grafts. Observational studies have suggested a survival benefit with two IMA grafts (BIMA) compared to SIMA, but this has not been tested in a randomised trial. ART is a MRC and BHF funded, multi-centre international trial comparing SIMA versus BIMA. Methods: Twenty centres in the UK, Australia, Poland and Brazil are planning to randomise 3000 CABG patients to SIMA or BIMA grafting. The primary outcome is survival at 10 years and secondary end-points include clinical events, quality of life and cost effectiveness. The effect of age, LV function, diabetes and off-pump surgery are pre-specified subgroups. Results: To date 1126 patients have been enrolled (recruitment to be completed by 2007). Group data are available so far on 903 patients. Mean age was 65 years (range 40–85) with 85% males. 92% of patients had the allocated revascularisation, 40% off pump, mean cardiopulmonary bypass time was 87 min (range 20–470), and a mean of 3 grafts performed (range 1–6). Seven patients (0.8%) had sternal wound dehiscence and 48 (5%) required renal support therapy. Thirty-day mortality was 1.2% (n=11 patients); 24 (3%) patients had re-explorations for bleeding; 14 had strokes (2%); 18 had myocardial infarctions (2%); 9 patients requiring further revascularisation (1%). Conclusions: ART is one of the first randomised trials to evaluate the effects on survival and other clinical outcomes of BIMA compared to SIMA, and will help to establish the best approach for patients requiring CABG surgery.
QEII Health Sciences Centre, Halifax, Canada Objectives: Diffuse coronary artery disease jeopardises myocardium, increasing surgical mortality in primary CABG. We sought to determine the impact of diffuseness on pre- and post-discharge outcomes for both primary and re-operative CABG (REOP). Methods: Using a validated system for measuring diffuseness of coronary disease, pre-operative angiograms were scored for primary CABG (n=792) and REOP cases (n=268) performed 1997–2004. A diffuseness score (DS) >18 was defined as elevated. In-hospital mortality, intermediate-term survival and in-hospital composite outcome (COMP) (one or more of: mortality, stroke, MI, deep sternal infection, sepsis, IABP insertion, or return to OR) were examined. Results: Crude in-hospital mortality and COMP for patients with DS>18 was significantly higher (7.9% vs. 2.4%, P<0.0001), (17.8% vs. 9.2%, P<0.0001). DS (mean±S.D.) was higher in REOP cases than primary CABG (18.9±7.1 vs. 14.4±6.0, P<0.0001). By multivariate analysis, DS>18 (OR 2.00, 95%CI, 1.20–3.32, P=0.008) and REOP (OR 2.40, 95%CI, 1.53–3.77, P<0.0001) were independently associated with COMP. Using propensity scores 82% of cases with DS>18 (n=289) were matched 1:1 to cases with DS=18. In-hospital mortality and COMP were significantly higher for cases with DS>18 (6.9% vs. 2.8%, P=0.02), (16.6% vs. 10.4%, P=0.03). Comparing cases with DS>18 vs. DS=18, survival at 2 years was 92.1% vs. 84.5% in the unmatched groups (P=0.001) and 87.4% vs. 92.6% in the matched groups (P=0.29). Conclusions: Diffuse coronary artery disease is an important predictor of morbidity and mortality in primary and REOP CABG patients, and should be considered in both individual patient assessment and risk adjustment.
Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan Objectives: The right gastroepiploic artery (RGEA) is widely used as an in situ arterial graft for CABG. However, it is impossible to measure an RGEA, check for calcification or stenosis, and assess its suitability as a graft, before angiography or harvest. We evaluated preoperative three-dimensional computed tomographic (CT) angiography for assessing the suitability of RGEAs for CABG. Methods: We used a 4-channel multidetector-row CT with intravenous nonionic-iodinated contrast medium. We divided the RGEAs, all with an intraluminar diameter greater than 1.5 mm, into three groups: ‘large’ RGEAs, longer than two-thirds of the greater curvature of stomach, ‘moderate’ RGEAs, longer than half the greater curvature and ‘small’ RGEAs, shorter than half the greater curvature. Results: Of the 36 patients examined, 5 (14%) had a small RGEA, 16 (44%) had a moderate RGEA, and 15 (42%) had a large RGEA. Intraoperative findings confirmed that two small RGEAs were unsuitable for grafting because they could not reach the posterior descending artery (PDA). The other three small RGEAs were not used. Two of the moderate RGEAs with diffuse narrowing and severe calcification were unsuitable for grafting. This eliminated the need for laparotomy to harvest the RGEA in these five (14%) patients. Intraoperative fingings confirmed that all the moderate RGEAs could be anastomosed to the PDA. All the large RGEAs reached the posterolateral artery (PLA) and more than half reached the PLA branching circumflex artery. Conclusions: This preoperative rapid and non-invasive evaluation by CT is effective for assessing the suitability of RGEAs for CABG.
1Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany; 2For the Departments of Thoracic and Cardiovascular Surgery of the Participating Centres, Lower Saxony, Germany; 3Department of Radiology, Hannover Medical School, Hannover, Germany Objectives: For the first time, technical developments in helical, high resolution 64-slice CT-scanning allow for analysis of cardiac pathology including coronary morphology. Here, we present results of a multi-centre study assessing the value CT-angiography as preoperative diagnostic tool in identifying target vessels for CABG surgery. Methods: 32 patients aged 64±9 years, 30 with confirmed coronary disease (angiography or scintigraphy) and 2 controls, underwent helical CT analysis. Scans were reviewed in a blinded fashion and potential target vessels for CABG were identified by 7 individual reviewers. Results were compared with those from conventional coronary angiography and to target vessels at surgery. Results: Results showed a high positive predictive value for targeting at surgery which was comparable for both conventional angiography and CT scan (LAD 100% vs. 97%, RCx 96% vs. 93%, 67% vs. 56%). In one patient, who presented with clinical signs of CAD and positive scintigraphy results, conventional angiography revealed no stenotic lesion and CT scan was used to confirm main stem disease. Conclusions: CT-angiography sufficiently allows for target vessel determination for CAGB. In individual cases, visual assessment of the left main coronary artery and the proximal LAD via CT-angiography may be superior to conventional angiography. However, while there is no difference in positive predictive targeting value, sensitivity and specificity of conventional angiography is still superior. Also, improvements in the methodology of evaluation and presentation of CT-findings are necessary. Our data suggest that CT-angiography may be used as a clinical alternative to conventional angiography in preoperative assessment for cardiac surgery.
1Erasmus Medical Centre Rotterdam, Rotterdam, Netherlands; 2Sint Antonius Hospital, Nieuwegein, Netherlands Objectives: To correlate supraclavicular ultrasonography at rest and in hyperaemic response with angiographically patent and (distal) string sign LIMA to LAD area grafts. Methods: Fifty-three patients with LIMA to LAD area grafting were prospectively entered in a follow-up study. Arteriography (native and LIMA) was performed at 1.4±0.8 year. postoperatively and ultrasonography was performed at rest, in hyperaemic response and 2 min after hyperaemic response at 1.8±0.8 year postoperatively and compared to arteriography. Ultrasonographic parameters analysed were: systolic and diastolic peak velocity, systolic and diastolic velocity integral, diastolic/systolic peak velocity ratio and diastolic/total velocity integral ratio. Results: One patient was excluded because obesity hampered ultrasonography. Arteriography demonstrated functional grafts in 43 patients (Group I), sequential distal string sign grafts in 4 patients (Group II) and total string sign grafts in 5 patients (Group III). Between the groups all ultrasonographic velocities showed a significant linear relation (P=0.004) at rest and during maximal hyperaemic response all velocities increased significantly within all groups (P=0.018). A significant decrease was found 2 min after hyperaemic response and diastolic velocities showed a significant linear relation (P=0.032). Conclusions: (Distal) String sign LIMA grafts were found in 9/52 (17.3%) patients. All patent and (distal) string sign LIMA grafts showed a shift towards a coronary flow profile in the proximal segment postoperatively. The ultrasound study revealed the ‘functionality’ of both the patent and the (distal) string sign LIMA graft in regard to myocardial oxygen demand. String sign grafts are ‘recruitable’ on demand.
Cardiothoracic Surgery of the University Hospital, Coimbra, Portugal Objectives: To develop and validate a risk model for in-hospital mortality for coronary surgery and to compare this model with three external risk-adjusted predictive models for mortality using an independent population of patients. Methods: Data on 4567 patients who underwent isolated coronary surgery were extracted from a prospective computerised database. Logistic regression was used to create and bootstrap re-sampling technique to validate a local risk model for in-hospital mortality. For comparative analysis, three others risk-prediction models-EuroSCORE, Parsonnet and Ontario Province scores – were used. The areas under the ROC (AUC) curves, to evaluate discrimination, and the Hosmer–Lemeshow (HL) test, to evaluate risk stratification systems at patient level, were utilised. Results: Multivariate risk factors included in the model were: age, reoperation, PVD, LV dysfunction and non-elective surgery. The logistic regression risk model showed good discrimination (AUC=0.752), excellent calibration (P=0.979) and high accuracy to predict overall mortality (0.99). Evaluation of the three external models in our population showed acceptable discrimination across all models. However, the predictive accuracy at patient level was poor (HL P<0.05) and the predictive overall mortality was inaccurate (observed mortality under the 95% CI limit of total predicted mortality) for all systems. Conclusions: Using five readily obtainable preoperative variables, we developed a risk-prediction chart for mortality that performs well. The AUC value across external risk models suggests that the systems perform moderately at which is useful for patient management. However, all but the local risk model showed poor predictive accuracy at patient level and inaccuracy in predicting overall mortality.
132 - O RISK FACTORS FOR AIRWAY COMPLICATIONS WITHIN THE FIRST YEAR AFTER LUNG TRANSPLANTATION C. Van De Wauwer1, D.E.M. Van Raemdonck1, G.M. Verleden2, L. Dupont2, P. De Leyn1, W. Coosemans1, P. Nafteux1, T. Lerut1 1Department of Thoracic Surgery, UZ Leuven, Belgium; 2Department of Pulmonary Medicine, UZ Leuven, Belgium Objectives: Lung transplantion (LTx) has enjoyed increasing success with better survival in recent years. Nevertheless, airway anastomotic complications (AC) are still a potential cause of early morbidity and mortality. In this retrospective study we looked at possible predictors of AC within the first year after LTx. Methods: Between July 1991 and December 2004, 232 consecutive single (n=102) and bilateral (n=130) LTx were performed (142 males and 90 females; mean age, 48 years [range 15–66 years]). Indications for LTx were emphysema (n=113), pulmonary fibrosis (n=45), cystic fibrosis (n=35), pulmonary hypertension (n=10), sarcoidosis (n=7) and miscellaneous (n=22). Donor (age, PaO2/FiO2, mechanical ventilation, ischaemic time) and recipient (age, diagnosis, length, gender, preop steroids, smoking, CMV matching, LTx type, anastomotic type, wrapping and bypass) variables were evaluated in a univariate and multivariate model. Results: Fifty-seven complications occurred in 362 airway anastomoses (15.7%) of which 55 (15.2%) within the first year after transplantation. Six patients died as a result of AC (mortality 2.6%) and 191 patients survived the first year after LTx (321 airway anastomoses). In a univariate analysis, anastomotic type (7/17 [telescoping] vs. 48/304 [end-to-end]; P=0.011), recipient length (P=0.0012), donor ventilation (>50–70 h; P=0.0015) and recipient male gender (43/191 [M] vs. 12/130 [F]; P=0.0092) were significant predictors of AC. Three factors remained significant predictors in the multivariate analysis: telescoping (OR: 3.121; P=0.0495), recipient length (OR: 1.065; P=0.0029) and donor ventilation (OR: 0.999; P=0.0029). Conclusions: Airway complications after lung transplantation remain a significant problem. Special surgical attention is needed in tall recipients and in those receiving lungs from donors with prolonged ventilation.
Division of Thoracic Transplantation, Heart Centre Leipzig, Leipzig, Germany Objectives: CPB support is required in some lung transplantation (LTX) operations requiring full dose heparin increasing the risks of bleeding. We report on our experiences of replacing CPB with heparin-bound low dose heparin ECMO support. Methods: From 2003 to 2005, 47 lungs (56% single) were transplanted and extracorporeal circulation support was necessary in 40% (7 CPB/8 ECMOs) always through femoral veno-arterial canulation. Limited access sternum sparing thoracotomies and normothermia occurred in all LTX on CPB (PPH 15%, COPD 15%, IPF with mean PAP>40 mmHg in 70%) or ECMO (PPH 13%, COPD 13%, IPF with severe PAP pressure elevation in 74%). Results: Operative time was longer (P=0.11) in the ECMOs (451 min±76 vs. 346 min±140). Red blood cell (RBC) requirements during the operation/24 h were increased in ECMO (P=0.001, 13.25±4.4 RBC vs. 3.1±2.2 on CPB). Ventilation times were markedly extended in the ECMO patients. The increased 90-day mortality rate showed a trend towards significance (P=0.056) in the ECMO group, which was related to infectious complications (3 vs. 1 patient). Severe ischaemia/reperfusion injury occurred in 9% in the CPB vs. 13% in the ECMO group. One year survival was reduced (P=0.004, log-rank test) in the ECMO patients. Conclusions: The advantages of femoral canulation rather than conventional central connections in LTX operations led to an undisturbed operative field. A significantly higher blood product amount was required in ECMO patients. The negative effects of transfusion in ECMO patients might contribute to the extended ventilatory times, infectious complications and mortality rates. CPB obviously appears to remain the standard of support techniques if extracorporeal circulation is required for lung transplantation surgery.
1Laboratory for Experimental Thoracic Surgery, Leuven, Belgium; 2Department of Thoracic Surgery, Leuven, Belgium; 3Laboratory for Pneumology, Leuven, Belgium Objectives: The use of non-heart-beating donors (NHBD) has been propagated as an alternative to overcome the scarcity of pulmonary grafts. However, formation of microthrombi after circulatory arrest is still a concern for the development of reperfusion injury. We looked at the effect and the best route of pulmonary flush after topical cooling. Methods: Non-heparinised pigs were sacrificed by ventricular fibrillation and divided in 3 groups (n=6/group). After 1 h of in situ warm ischaemia and 2.5 h of topical cooling, lungs in Group I were retrieved unflushed [NF]. In Group II, lungs were explanted following an antegrade flush [AF] through the pulmonary artery with 50 ml/kg Perfadex®. Finally, in Group III, lungs were explanted after an identical but retrograde flush [RF] via the left atrium. Flush effluent was sampled at intervals to measure haemoglobin concentration. Performance of the left lung was assessed during 60 min in our ex-vivo reperfusion model. Results: Haemoglobin concentration (g/dl) was initially higher after RF vs. AF (3.4±1.1 vs. 0.6±0.1) (P<0.05). Pulmonary vascular resistance (dynes*sec*cm-5) was 975±85 [RF] vs. 1567±98 [AF] and 1576±88 [NF] at 60 min of reperfusion (P<0.001). Oxygenation (mmHg) and compliance (ml/cm H2O) were higher and plateau airway pressure (cmH2O) was lower after RF vs. AF and NF (491±44 vs. 472±61 and 430±33 [NS]; 22±3 vs. 19±3 and 14±1 [NS]; 11±1 vs. 13±1 and 13±1 [NS], respectively). No differences in W/D were observed after reperfusion. Conclusions: Retrograde flush in the non-heart-beating donor results in a more effective flush-out and subsequent reduced pulmonary vascular resistance upon reperfusion.
1VAMC and University of Pennsylvania, Philadelphia, USA; 2University of Pennsylvania, Philadelphia, USA Objectives: Severe primary graft dysfunction caused by ischaemia/reperfusion (I/R) injury occurs in 10–20% of lung transplant recipients and is the leading cause of early death. We tested the protective effects of catalase targeted to pulmonary endothelium by conjugation with antibody to PECAM-1, in a murine model of lung I/R. Methods: Conjugates A (anti-PECAM IgG-catalase) and B (control non-immune IgG-catalase) were prepared using amino-based chemistry. Sulfhydryl and maleimide groups reactive towards sulfhydryl were introduced in IgG and catalase to produce 300-nm nanoconjugates. Anti-PECAM/125I-catalase but not IgG/125I-catalase accumulated in mouse lungs after intravenous injection. Mice were mechanically ventilated (FiO2 21%, TV 10 ml/kg, RR 130/min). Saline, Conjugate A or B (0.1 ml, 60 µg catalase) was injected intravenously. Thoracotomy was performed, the left hilum clamped for 60 min and reperfused for 60 min. Sham animals (undergoing thoracotomy, but not I/R) were used as controls. Arterial PaO2, saturation, and bronchoalveolar lavage (BAL protein, mg/ml) were evaluated as physiologic and biologic parameters of I/R injury (n>4, all groups blinded, P<0.05, ANOVA). Results: Four groups were studied: Sham, mice pre-treated with saline (Saline), Conjugate A or B. Conjugate A had significant improvement in arterial PaO2 and saturation (79±4 vs. 54±2 PaO2; 88±1 vs. 70±4 saturation, respectively) and a significant decrease in BAL protein (0.06±0.01 vs. 1.0±0.05) compared to saline. Conjugate B did not have significant improvement in arterial PaO2, saturation or lung BAL protein compared to saline. Conclusions: Targeted anti-oxidant therapy protects against I/R injury and may be useful in primary lung graft dysfunction.
136 - O RECURRENCE OF MITRAL REGURGITATION PARALLELS THE ABSENCE OF LEFT VENTRICULAR REVERSE REMODELLING AFTER MITRAL REPAIR IN ADVANCED DILATED CARDIOMYOPATHY M. De Bonis, E. Lapenna, A. Verzini, G. La Canna, A. Grimaldi, L. Torracca, F. Maisano, O. Alfieri Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy Objectives: To assess the occurrence of LV remodelling after effective mitral valve (MV) repair in advanced dilated cardiomyopathy (DCM) and its impact on clinical outcome and repair durability. Methods: Out of 111 patients undergoing MV repair in advanced DCM, 79 patients with no or trivial residual MR at discharge were included in this study. Preoperatively they had 3–4+ functional MR, EF 28±5.5%, LVEDV 200±58 ml, LVESV 145±46.4 ml, tenting area 2.7±0.9 cm2, coaptation depth 1.1±0.3 cm, NYHA 2.9±0.7. A complete, rigid/semirigid undersized ring annuloplasty (with or without ‘edge-to-edge’) was used. Concomitant CABG was performed in 41 patients.
Results: At a mean follow-up of 2±1.3 years, LV reverse remodelling was documented in 41 (51.8%) patients whereas in 38 (48.1%) LV dimensions remained unchanged or increased compared to preoperative values. The persistence/progression of LV remodelling paralleled the recurrence of MR and worsening of symptoms. Recurrence of MR Conclusions: In patients with functional MR undergoing effective repair, reverse LV remodelling occurs in about 50% of the cases and is associated to longer repair durability and a better clinical outcome compared to those with persistence/progression of the remodelling process.
Department of Cardiac Surgery, University G D Annunzio, Chieti, Italy Objectives: To identify predictive variables for recurrence of mitral regurgitation (r-MR) in patients with dilated cardiomyopathy (DCM) undergoing mitral valve (MV) repair. Methods: From 1997 to 2005, 142 patients with DCM underwent MV repair. 97 (70% ischaemic, 30% non-ischaemic), still alive at follow-up, were included in this retrospective analysis. Mean age was 66±10 years; NYHA class was 3.0±0.7. MV posterior annuloplasty was performed in all cases (autologus pericardium 36%, suture annuloplasty 21%, posterior ring 43%). Mean MR grade was 3.2±0.8; end-diastolic(EDV) and end-systolic(ESV) volume were 122±27 and 81±21 ml/m2; ejection fraction(EF) 31%±5; coaptation dept (CD) 9.2±2.0 mm. Echographic control was performed in all cases after 44±28 months to evaluate r-MR (32+). Four-year freedom from r-MR was performed by Kaplan-Meier method. Cox-analysis was performed to identify predictive variables; ROC-curve was used to found the predictive cut-off values. Odds-ratio (OR), p-value, area under curve (AUC) were reported. Results: Four-year freedom from r-MR was 65.5%±8.3. Mean MR grade at follow-up was 0.9±0.9 (grade 0, 37.1%, 1+ 43.3%, 2+ 14.4%, 3+ 4.2%, 4+ 1.0%). Predictive variables were: EDV (OR=1.03, P=0.016, AUC=0.72), ESV (1.03, 0.033, 0.71), EF (0.82, 0.001, 0.72), CD (1.6, 0.017, 0.72). Cut-off values were: EDV3130 (OR=3.4, P=0.029), ESV=385 (3.1, 0.038), EF£30% (4.4, 0.008), CD >10 mm (3.1, 0.034). Furthermore presence of moderate MR (6 patients) at the hospital discharge was an independent variable (4.1, 0.017). Operative technique was not a risk factor. Conclusions: Preoperative left ventricular dilatation and function along with degree of papillary muscle displacement can be helpful to identify patients with higher probability to undergo a durable MV repair. Moreover moderate MR in the early postoperative period cannot be considered acceptable.
Manchester Heart Centre, Manchester Royal Infirmary, Manchester, UK Objectives: We analysed retrospectively the patients who underwent mitral valve repair using alternative to the French correction techniques. Methods: From June 1997 to March 2006, 128 patients (87:41) with mean age 64.1±12.8 years (range, 22–87) underwent mitral valve repair. Combined procedures for IHD were performed in 42 cases. Five cases were urgent. Mean Euroscore was 4.9±2.1 (range, 2–13). Type I lesions were present in 31 cases, type II in 95 and type III in 2. Preoperative MR was severe in 120 cases, while NYHA was III/IV in 74 cases. The transeptal approach was performed in 115 cases. Edge-to-edge technique was used in 63 cases (annuloplasty in 34), triangular exclusion in 35 (anterior leaflet in 2) and annuloplasty alone in 30. Mean number of grafts in combined cases was 2.1±0.9 (range, 1–4).
Results: Mean postoperative stay was 8.2±3.8 days (range, 4–25). There was no mortality in the isolated mitral valve repair. Two patients died in the combined group due to ischaemic pathology. AF occurred in 22.7% and further morbidity was 7%. Mean follow-up was 34.5±25.7 months (range, 0–105). No/mild MR presented in 114 patients while 119 were in NYHA class I. Two patients underwent a redo repair. There were 4 late deaths from unrelated causes. There was no significant difference between edge-to-edge technique and the others for the postoperative MR and NYHA status (P=0.099/0.32). There was strong relationship between the edge-to-edge technique and concomitant annuloplasty with better postoperative MR status (P=0.001), but not with NYHA status (P=0.43) ( Conclusions: Our study demonstrates that the alternatives to the French correction techniques are associated with excellent early and late outcome. They simplify the repair procedure particularly in the combined procedures. These techniques have been applied with no mortality in the isolated mitral valve repair group and low mortality in the combined group.
Cardioteam Clinica San Gaudenzio, Novara, Italy Objectives: Feasibility and reliability of mitral valve reconstruction in patients with degenerative mitral insufficiency secondary to involvement of both mitral leaflets, have been retrospectively evaluated. Methods: From January 1 1996 to March 15 2006, 331 consecutive patients with degenerative mitral incompetence due to prolapse of both leaflets, underwent surgical correction. In 318 patients (96.1%) repair was accomplished by reconstruction of the chordae tendineae with polytetrafluorene (PTFE) sutures on the anterior leaflet and implantation of a flexible annuloplasty ring. Quadrangular resection and sliding plasty were also generally performed to treat the involvement of the posterior leaflet. In 16 patients (4.9%) the repair was accomplished (9 cases) or completed (7 cases) by means of a single ‘edge-to-edge’ stitch. 4 patients (1.2%) received prosthetic valves. All patients who underwent repair had either no regurgitation or trivial to mild incompetence at the end of the surgical procedure. Results: Hospital mortality was 0.9%. Follow-up (3 months–10 years, average 5.2 years) was performed in 317 cases (97%). No cardiac related late mortality was recorded; six patients (1.9%) presented late failure of the repair which required a second procedure. Four patients (1.3%) showed at echocardiogram stable moderate recurrent mitral insufficiency that, at present, does not require further surgical correction. Echocardiographic controls demonstrate in 307 patients trivial to mild mitral incompetence. Conclusions: The majority (93.5%) of patients with pure mitral insufficiency with involvement of both leaflets of the mitral valve, physiological single-orifice repair is feasible with low mortality and low medium-term recurrency rate. Repair utililising an ‘edge-to-edge’ stitch, may find an occasional indication in few patients. Valve replacement is seldom necessary.
Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany Objectives: We report our 9-year experience with minimally invasive mitral valve operations using the trans-thoracic clamp technique, including morbidity and mortality as well as echocardiographic follow-up results. Methods: Since 1997, 276 patients (133 males, aged 57±13 years) underwent minimally invasive mitral valve surgery through right thoracotomy using the transthoracic clamp technique. Reconstructions were done in 227 patients, and 49 valves were replaced. Complex mitral valve procedures were performed in 193 cases. Mean length of incision was 7.0±1.4 cm. Mean preoperative New York Heart Association functional class was 2.7±0.9. Results: Thirty-day mortality was 2.9% (n=8). Operating, bypass and cross-clamp times averaged 236±51, 138±39 and 82±24 min, respectively. Seven patients (2.5%) had conversion to sternotomy. Nine patients (3.2%) underwent re-exploration for bleeding. Mean intensive care unit and hospital stay were 17 h and 7.9 days, respectively. Mean follow-up was 48±19 months. Echocardiographic follow-up documented persistently competent valve function in all but 7 patients who had grade III regurgitation. Five of them underwent mitral valve re-reconstruction, one had replacement and one underwent transplantation. At 96 months, freedom from non-trivial recurrent mitral regurgitation and re-operation, were 91.3% and 94.8%, respectively. Actuarial survival at 96 months, including early mortality, was 90.2%. All thoracic wounds were free from infection. Conclusions: This study demonstrates that direct vision, transthoracic clamp technique for minimally invasive mitral valve surgery is reproducible with low mortality and morbidity. It results in excellent cosmesis and abolished risk of thoracic wound infection. Results are comparable to outcomes of conventional operations.
141 - I ENDOSCOPIC INTERCOSTAL NERVE INTERPOSITION IN PATIENTS WITH SEVERE COMPENSATORY HYPERHIDROSIS J.J. Hwang2, H.C. Paik1, D.Y. Lee1 1Yongdong Severance Hospital Yonsei University College of Medicine, Seoul, Korea (South); 2Eulji University College of Medicine, Daejeon, Korea (South) Objectives: Resection of thoracic sympathetic nerve is an effective method in the treatment of hyperhidrosis but compensatory sweating is annoying factor in this method. We tried to interpose intercostal nerve to sympathetic ganglion (third intercostal nerve to the first thoracic sympathetic nerve) for the purpose of reversing compensatory sweating. Methods: From February 2004 to November 2005, intercostal nerve interposition was performed in 9 patients. The patients underwent sympathicotomy due to facial (3 cases) and palmar (6 cases) hyperhidrosis before interposition surgery. They were followed up by the telephone questionnaire, and the degree of sweating and satisfaction rate were analyzed. Results: Mean age of the patients was 36.1±18.2 years (range: 19–64 years) and 33.3% were female. Previous operations were T2 sympathicotomy in 4 cases and T3 sympathicotomy in 5 cases. The intervals between sympathicotomy and nerve interposition were 43.9 months. Mean operation time and follow up periods were 198.3±103.7 min and 6.7±7.2 months. Compensatory sweating has decreased mildly in five patients (55.6%) after nerve interposition and satisfaction rate was 55.6%. Conclusions: The exact reason for decreasing in truncal sweating after nerve interposition was unclear but connection between intercostal nerve and sympathetic ganglion may influence in restoring thermoregulation. More efforts are needed to reveal the mechanism and method of decreasing compensatory sweating.
1Thoracic Surgery, Florence, Italy; 2Nuclear Medicine, Florence, Italy Objectives: Our aim was to evaluate the best intrathoracoscopic localisation technique in patients with single pulmonary nodule. Methods: From January 2000 to January 2005 we've enrolled 50 patients, divided into two groups, well matched for diameter and depth of the lesion. In 25 patients we performed radio-guided localisation (Group A), whereas in the other 25 patients the hookwire technique was adopted (Group B). In both group the localisation techniques were compared with finger palpation. In both groups, the distance of the nodule from the pleural surface with lung inflated was 2.5±0.8 cm (1.7–2.5 cm in 12 patients, and >2.5 cm for the remaining 13). The mean size of the nodules in both groups was 1.1 (range 0.6–1.9). All patients underwent thoracoscopic wedge resection, and 23 patients underwent thoracotomy for lobectomy and mediastinal lymphadenectomy. Results: In Group A, radio-guided surgery localised the nodule in 24 of 25 patients (96%) whereas finger palpation localised it in 6 of 25 (24%). In Group B, both the hookwire and finger palpation techniques localised the nodule in 21 of 25 patients (84%). In Group B we've registered 6 cases of pneumothorax and 3 cases of dislocation of the guide, in Group A 1 case of pneumothorax. Conclusions: In our experience radio-guided surgery has been proven to be efficacious in the diagnosis of SPN. Nevertheless, we must also stress that the method utilised in group B was also shown to be efficacious, demonstrating a low percentage in complications linked primarily to external technical factors.
Thoracic Surgery University of Torino, Torino, Italy Objectives: Adenosquamous carcinoma (ASC) is a composite tumor exhibiting simultaneous squamous and glandular differentiation in the same mass. We compared clinico-pathologic characteristics, staging and survival in ASC, squamous cell carcinoma (SCC) and adenocarcinoma (ACA) resected in a similar time period. Methods: In the period 1994–2005, 40 ASC, 724 SCC and 694 ADA were operated on. Among ASC, histologic grading was G2 (12 cases) and G3 (22 cases). Morphologic characteristics included vascular invasion (21 cases), perineural invasion (9), peritumoral lymphocytic infiltrate (4). Surgical operations included wedge resection/segmentectomy (6 patients), lobectomy/bilobectomy (20), pneumonectomy (12), Pancoast's tumor (2). Post-surgical staging revealed 7 Stage I, 8 Stage II, 16 Stage IIIa, 3 Stage IIIb, 3 Stage IV (M1 intrapulmonary) tumors. Mean tumor dimension was 4.4 cm (ADA 3.8 and SCC 4.3, P=0.2). Results: Univariate analysis performed on such variables as morphologic characteristics, dimension, visceral pleural invasion and stage indicate that ASC showed more vascular invasion than SCC but similar to that of ADA and a higher pathologic stage at surgery (P=0.02). Overall 3-year survival was 22% for ASC, 56% for SCC and 51% for ADA (P=0.00001); survival by N factor was significantly different in N0 patients (ASC 30%, SCC 68%, ADA 60%, P=0.005), but not in N2 patients (ASC 10%, SCC and ADA 30%, P=0.13). Conclusions: ASC is a more aggressive histotype than SCC and ADA. A higher stage at presentation and a poorer survival particularly in early stages are expected. Adjuvant chemotherapy should routinely be considered following resection of ASC irrespective of the stage.
Siauliai Public Hospital, Siauliai, Lithuania Objectives: The influence of clinicomorphological data on 5-year survival (5YS) and life span (LS) of non-small lung cancer (LC) patients (LCP) after complete en bloc pneumonectomies and lobectomies (R0) was investigated. Methods: In trial (1985–2006) the data of consecutive 425 LCP (age=56.4±0.4 years; male=382, female=43; tumor diameter: D=4.4±0.1 cm; pneumonectomy=185, lobectomy=240, combined procedures with resection of pericardium, atrium, aorta, v. cava superior, carina, diaphragm, ribs=63) with stage T1-4N0-2M0 (squamous=274, adenocarcinoma=124, large cell=27; T1=124, T2=196, T3=86, T4=19; N0=234, N1=104, N2=87; G1=102, G2=109, G3=214) was reviewed. Survival curves were estimated by Kaplan-Meier method. Neural networks computing, Cox regression, clustering, discriminant analysis, structural equation modelling, Monte Carlo and bootstrap simulation were used to determine any significant regularity. Results: For total of 425 LCP overall LS was 1674.5±54.1 days and 5YS reached 59.1%. 251 LCP (age=56±0.5 years; male=222, female=29; LS=2446.7±46.5 days; D=4.1±0.1 cm) lived more than 5 years without LC progressing. 174 LCP (age=55.9±0.6 years; male=160, female=14; LS=560.8±29.2 days; D=4.8±0.2 cm) died because of LC during first 5 years after surgery. It was revealed that 5YS (LS) of LCP after resections significantly depended on (P=0.039-0.000): (1) phase transition ‘early LC-invasive LC’; (2) level of blood cell subpopulations circuit; (3) ratio of LC cells to blood cell subpopulations; (4) LC characteristics; (5) hemostasis system; (6) biochemic data; (7) hematological factors; (8) procedure type; (9) anthropometric data. Conclusions: Correct prediction of LCP survival after surgery was 84% by logistic regression, 85.8% by discriminant analysis and 100% by neural networks computing (error=0.0017; urea under ROC curve=1.0).
1Division of General Thoracic Surgery, Bern, Switzerland; 2Division of Cardiovascular Surgery, Bern, Switzerland; 3Pulmonary Division, Bern, Switzerland; 4Division of Nuclear Medicine, Bern, Switzerland Objectives: Primary pulmonary artery sarcomas (PPAS) present rare mesenchymal tumors which are frequently misdiagnosed as unilateral pulmonary embolism. Mean survival without surgical intervention is only 1.5 months. Methods: Three patients with PPAS who underwent extended pneumonectomy with reconstruction of the remaining pulmonary artery on cardio-pulmonary bypass between August 2003 and December 2004 are presented. Results: Patients were male and 30, 47 and 78 years old. All patients have been initially diagnosed by spiral contrast-enhanced CT-scan as having massive unilateral pulmonary embolism, and received heparine followed by oral anticoagulation. In all cases, duplex sonography of the lower extremities revealed no deep vein thromobosis, and chest MRI demonstrated no gadolinium enhancement. In contrast, in all patients PET scan revealed a tumor-typical increase in tracer uptake (F-18 fluorodeoxyglucose) with no signs of either mediastinal, pulmonary or distant metastasis. On postoperative histological examination, angiosarcomas grade II to III were found with no spread to intrapulmonary or hilar lymph nodes and resection margins being free. All patients are followed by clinical examination and chest CT scan. Within a follow-up of 15, 19 and 31 months, no signs of recurrence have been observed. Conclusions: Patients diagnosed as suffering unilateral pulmonary thromboembolic disease who clinically do not respond to an adequate systemic anticoagulation and in whom no source of thromboembolic disease can be found, shall undergo FDG-PET scan. Otherwise, PPAS may be misdiagnosed as deaths due to massive unilateral chronic pulmonary embolism. Radical resection with vascular reconstruction is technically feasible, and may offer long term survival.
1National Hospital Organization, Himeji Medical Center, Himeji, Japan; 2Tenri Hospital, Tenri, Japan Objectives: Carinal reconstruction is one of the most challenging procedures with high morbidity and mortality. We developed new technique and surgical results were reviewed. Methods: Between 1989 and 1999, fourteen patients underwent carinal resection and reconstruction by new technique. In this technique, two thirds of the circumference of the trachea and the left main bronchus is anastomosed first. After one ring of cartilage is trimmed from the remaining one third of the circumference, the right bronchus is anastomosed end-to-side to this trimmed site. Results: Carinal resection plus right upper lobectomy was performed in 12 patients and carinal resection plus right upper-middle bilobectomy in two. Superior vena caval resection was combined in 4 patients. One patient died postoperatively by dehiscence and broncho-arterial fistula (7.1%). Major anastomotic complication occurred in 4 patients (dehiscence in 1 and stenosis in 3) (28.5%). One of 3 stenosis resolved with ballooning and this patient survived 5 years but the remaining two patients died with respiratory problems caused by stenosis. Overall survival was 57.1% at 2-year and 28.5% at 5-year. Survival was better in patients with N0 disease (n=9) than those with N2 disease (n=5) (44.4% vs. 0% at 5-year, respectively). Conclusions: This technique for carinal reconstruction is feasible with acceptable morbidity and mortality. Anastomotic complications are related with high mortality. Positive N2 disease should be considered a potential contraindication to this tech.
147 - O STENT-GRAFTING OF THE THORACIC AORTA BY THE CARDIOTHORACIC SURGEON B. Zipfel, S. Buz, R. Hammerschmidt, T. Krabatsch, Y. Weng, R. Hetzer Deutsches Herzzentrum Berlin, Berlin, Germany Objectives: We evaluated endovascular stent-grafting as a new technique in cardiothoracic surgery. Methods: Two hundred, 2 Endofit®(sixteen stent-grafts (123 Talent®, 77 E-vita®, 6 Zenith®, 6 Relay 1 Valiant® and 1 Gore-TAG®) were implanted in the thoracic aorta in 191 patients (70% male; age 15–87, mean 61 years). All procedures were performed by a team of cardiothoracic surgeons in the operating room with a mobile C-arm with digital subtraction angiography; 123 operations (57%) were emergency procedures. Twenty-four procedures (11%) were reoperations for endoleaks. The left subclavian artery origin (LSA) was covered in 56 cases and the left common carotid artery (LCCA) in 2 cases. Access was by femoral cut-down in 195 procedures, percutaneous femoral approach in 1 and by conduit to the iliac arteries or infrarenal aorta in 20. Surgical reconstruction of damaged access vessels became necessary in 10 cases. Results: Thirty-day mortality was 9.7% (19 patients). Spinal cord ischaemia occurred in 1.5% (3 patients). Primary technical success was achieved in 85.2%, secondary (after further interventions) in 92.6%. Six conversions to open repair were necessary, three during the procedures and 3 secondarily before discharge. Conclusions: The results are excellent taking into account the high incidence of emergency procedures and that open surgery is not promising in many patients. The cardiothoracic surgeon can adopt this new technique easily. Cardiothoracic surgical skills, however, are mandatory because of the potential need for conversion to open repair and for extensive surgical approach to the access vessels.
Medical University Vienna, Vienna, Austria Objectives: Alternative treatment approaches in elderly patients with aortic arch diseases are now available. Mid-term results of these strategies are uncertain. Methods: From October 2002 to March 2006, 23 patients (mean age 72.4 years) presented with aortic arch diseases (arch aneurysms n=20, type B dissections n=3). Strategy for distal arch disease was autologous sequential transposition of the left carotid artery and of the left subclavian artery in 14 patients. Strategy for entire arch disease was total supraaortic rerouting using a reversed bifurcated prosthesis in 9 patients. Endovascular stent-graft placement was performed thereafter. Results: Two in-hospital deaths occurred (myocardial infarction on the day prior to discharge n=1, rupture while waiting for stent-graft placement n=1). At completion angiography, all reconstructions were fully patent. Four patients had small type Ia endoleaks resolving spontaneously. Mean follow-up is 14 months (1–41 months). Three late deaths occurred (myocardial infarction n=2, sudden unknown death n=1). One-year survival was 83% and three-year survival was 72%, respectively. Redo stent-graft placement was performed in one patient after 25 months (type III endoleak). The remaining patients had normal CT scans with regular perfusion of the supraaortic branches without any signs of endoleaks. Conclusions: Mid-term results of alternative treatment approaches in elderly patients with aortic arch diseases are satisfying. Extended applications provide safe and effective treatment in patients at high risk for conventional repair.
Sapporo Medical University School of Medicine, Sapporo, Japan Objectives: We reviewed our experience to investigate the determinants of paraplegia/paraparesis after endovascular stent-graft repair of the thoracic aorta, to assess the influence of the artery of Adamkiewicz (ARM) detected by preoperative magnetic resonance angiography (MRA) and to identify patients at risk. Methods: During a 5-year period (March 2001 to February 2006), 140 patients underwent elective endovascular stent-graft repair of the descending thoracic aorta. Fenestrated stent-graft was deployed in twenty-two patients with zone 0 and zone 1 aortic distal arch aneurysms. Patient demographics and perioperative factors relating to the endovascular procedure were evaluated by using univariate statistical analyses. To assess the influence of the ARM in the thoracolumbar region, patients in whom ARM was detected by preoperative MRA were divided into two groups: patients who had occlusion of the intercostal artery for ARM due to stent-graft (Group I, n=30) and patients who had patency of the intercostal artery for ARM following stent-graft (Group II, n=38). Results: Five (3.6%) of the 140 patients had paraparesis/paraplegia. Two of these 5 patients had previously undergone operation for total arch replacement with elephant trunk and 1 had had surgery for descending aortic repair. Univariate analyses identified only prior aortic surgery (TAA) as a significant risk factor (P<0.004). Paraparesis/Paraplegia rates were 10% (3 patients) in Group I and 0% in Group II (P<0.08). Conclusions: Prior thoracic aortic replacement was found to be a significant predictor of spinal cord ischaemia, and therefore vigilance is needed regarding patient's occlusion of the intercostal artery for ARM detected before stent-graft repair.
1Department of Cardiovascular Surgery University Hospital, Freiburg, Germany; 2Department of Neurology University Hospital, Freiburg, Germany Objectives: Endovascular stentgraft implantation is associated with lower morbidity and mortality than open aortic repair. Overstenting of the left subclavian artery to create a satisfactory landing zone can become an unavoidable treatment to ensure optimal fit of an endovascular stentgraft. There are only a few cases reporting about neurological complications after aortic stentgrafting. We evaluated, if overstenting of the left subclavian artery is associated with a higher risk of neurological complications. Methods: Between December 2000 and February 2006, 20 patients suffering from aortic aneurysms or type B aortic dissections received stentgraft repair in which the subclavian artery was completely (14 patients, 70%) or partially (6 patients, 30%) overstented. In three cases (15%) aortic-bicarotid bypass grafting was performed before the aortic arch was completely overstented. Results: Aortic stentgraft repair was successful in each operation. Two patients (10%) suffered from neurological complications associated with a subclavian steal syndrome. Within 4 months the first patient developed sensory and motor neurological deficits of the left arm and was treated with a left carotid-subclavian bypass. The second patient had a stroke 2 months after the first operation and received subclavian transposition on the left carotid artery. Conclusions: Stenosis or occlusion of the supraaortic branches are preoperative risk factors and can lead to a higher rate of neurological complications after overstenting of the left subclavian artery. Preoperative exploration with duplex sonography is mandatory. If stenoses of the supraaortic branches, especially of the vertebral arteries are detected, we recommend subclavian transposition or carotid-subclavian bypass before stentgraft implantation.
1Department of Cardiac Surgery, University Hospital Schleswig, Holstein Campus Luebeck, Luebeck, Germany; 2Deparment of Cardiology, University Hospital Schleswig, Holstein Campus Luebeck, Luebeck, Germany Objectives: It is not clear if aortic stenting in the acute setting of type B dissection will increase the incidence of early and late complications that require consecutive surgery. In this retrospective study we reviewed our results of secondary surgery for complications after prior emergency placement of aortic stents for acute type B dissection. Methods: From October 2000 to December 2005, endovascular stent-grafting was performed in 13 patients (mean age: 61.3±6.2 years, range: 46–71 years) as an emergency procedure for acute type B dissection. Indications for acute intervention included haematothorax, contained rupture, life-threatening malperfusion and refractory pain. After surgical exposure of the iliac or femoral arteries self-expanding nitinol stents (mean diameter: 39±5 mm) were placed into the descending aorta distal to the left subclavian artery. Before discharge and on follow-up aortic imaging was performed using computed tomography. Results: Three patients (23%) required consecutive surgical treatment after emergency endovascular stent-grafting for acute type B dissection. Two complications occurred early after aortic stenting, one late. Indications for surgery included (1) the development of acute retrograde type A aortic dissection and (2) stent dislocation by fractured wires and secondary leakage. Elective surgery was necessary in one patient 6 months after stent-grafting for late formation of an aneurysm of the descending aorta. There were no surgical deaths and no major morbidity. Conclusions: In a significant number of patients emergency stent-grafting for acute type B aortic dissection results in complications that require secondary surgical treatment. However, compared to primary surgery of acute type B aortic dissection which often leads to poor results, the surgical treatment in more chronic (non-emergency) stages for complications after EVSG for acute type B aortic dissection results in more predictable and better outcome.
152 - I A PROSPECTIVE RANDOMISED COMPARISON OF MOSAIC AND LABCOR VALVES IN AORTIC VALVE REPLACEMENT B. Meuris, P. Herijgers, M–C. Herregods, W. Flameng University Clinic Gasthuisberg, Leuven, Belgium Objectives: This prospective randomised study compares two porcine stented bioprostheses in early haemodynamic performance at patient discharge and 1 year postoperatively. The major difference between these two stented valves is the lack of any antimineralisation treatment in the Labcor valve. Methods: Between November 2000 and February 2003, 157 patients were randomised to receive either a Mosaic (n=79) or a Labcor (n=78) valve in aortic position. Transthoracic echocardiography was performed to assess haemodynamic data preoperatively, at patient discharge and 1 year postoperatively. Results: Both groups were comparable regarding age-, sex- and body surface area (BSA) distribution. Implanted valve sizes and intraoperative parameters were similar. Follow-up was 99.6% complete. At patient discharge, the Labcor valves already revealed higher gradients (P=0.04), with slightly lower effective orifice area (EOA) values. At 1 year postoperatively, mean and peak gradients were significantly higher in the Labcor group (P=0.004 and P=0.01 respectively), with significantly lower EOA values (P=0.02). These differences were observed across all valve sizes, but were most prominent in the 21-, 23- and 25-mm valves. One Labcor valve was explanted after 15 months for early prosthetic valve failure. Prosthetic valve insufficiency >1/4 after 1 year was observed in three Labcor valves, while none of the Mosaic valves showed this. Conclusions: Compared to the Labcor valve, our data show a significant superiority of the Mosaic concerning pressure gradients and EOA one year postoperatively. Minor design differences and possibly the lack of anticalcification treatment in the Labcor could be responsible for these early differences.
Manchester Heart Centre Manchester Royal Infirmary, Manchester, UK Objectives: CorTemp is a wireless, non-invasive, intestinal temperature monitoring system in the form of a pill. The system's validity and practicality were evaluated under the extreme body core temperature variations of cardiac surgery. Methods: A repeat measures design using simultaneous temperature readings from the pulmonary artery (Tpa), nasopharyngeal (Tnp), skin thermometers (Tsk) and the CorTemp system (Tin), was conducted in 15 patients undergoing elective cardiac surgery under hypothermic conditions (28–32 °C). Statistical analysis included Bland-Altman and the paired t-test. Results: Only 66.67% of patients were analysed; four patients were cancelled following ingestion of the probe, another patient underwent surgery under deep hypothermia. 264 sets of readings were recorded while Tin data was incomplete for two of the patients. Bland-Altman analysis showed Tin bias (average mean difference) of –0.33–0.66 °C with Tpa, –0.50–0.76 °C with Tnp and 0.12–1.91 °C with Tsk. Limits of agreement (±2 standard deviations) between Tin and Tpa, Tnp and Tsk varied from ±0.35 to ±1.53 °C, ±0.72 to ±1.63 °C and ±0.40 to ±1.84 °C, respectively. Tin bias was significantly different from Tpa (P=0.0023), Tnp (P=0.018) and Tsk (P=0.0005) during rewarming. Tin rate of temperature change was also found to be significantly slower during the rewarming period. Conclusions: CorTemp is a low cost, minimally invasive, monitoring system. However the significant bias and slower rate of temperature change during rewarming detected by CorTemp compared to Tpa and Tnp, urge caution regarding its use as an accurate estimator of brain temperature in cardiac surgery, but may be a promising alternative for body core temperature monitoring. Reliability and practicality issues however limit CorTemp's functionality at present.
Hospital Universitario De Canarias, Tenerife, Spain Objectives: To determine if there are genetic polymorphisms associated with coagulation, fibrinolysis and inflammation, that can affect post-operative bleeding in patients submitted to cardiac surgery under extracorporeal circulation (ECC). Methods: 26 patients who didn't receive anti-fibrinolytic treatment were submitted to elective cardiac surgery under ECC. Data were compiled related to coagulation, complement and fibrinolysis, preoperatively, at admission to the ICU at 4 and 24 h. Bleeding and its relationship with the different polymorphisms were analysed: insertion/delection (I/D) in the intron 16 of the gene of the angiotensin converting enzyme (ACE); the polymorphism G1691A of the factor V gene (Leiden); the polymorphism G20210A of the factor II gene; the polymorphism 4G/5G of the plasminogen activator inhibitor gene (PAI-1); Alu-repeat insertion/delection (I/D) of the tissular plasminogen activator gene (tPA) and the polymorphism of F+250); ß the first intron the tumoural necrosis beta factor gene (TN). Results: (1) the insertion/delection (I/D) polymorphisms of the ACE gene (P=0.046), of the PAI-1 (P=0.037) and of the TNF+250 (P=0.029); were associated with greater bleeding in the 24 h post-operative period. (2) The GG Homozygots (TNF+250) presented higher basal plasmatic levels of IL-6 (P 0.01). (3) Homozygots 5.5 of the PAI-1 polymorphism were associated to lower levels of complement: C1-inhibitor (P=0.038) and C7 (P=0.016); of leptines (P=0.019) and of PAI-1 (P=0.019). Conclusions: We have identified three genetic polymorphisms associated with post-operative bleeding that can help us to stratify the pre-operative risk in heart surgery under ECC to optimise prophylactic therapeutic measures.
San Raffaele Hospital, Milan, Italy Objectives: The minimally invasive closed circuit system (MECC) is a low priming circuit with no blood-air interface. We wanted to evaluate the safety the technical feasibility and clinical results of aortic valve replacement performed with MECC compared to standard cardiopulmonary bypass. Methods: Eighty consecutive patients undergoing isolated aortic valve replacement in a single institution were randomly assigned to either a miniaturised closed circuit CPB with the Maquet-Cardiopulmonary MECC System Ó (Study Group B, n=40) or to a standard cardiopulmonary bypass (Control Group A, n=40). Results: Demographic characteristics and operative data were similar in the two groups. There was no in-hospital mortality, patients in Group A showed lower chest tube drainage (217±68 ml vs. 340±229 ml, P=0.05) and need for blood products (6.6% vs. 43.3%, P=0.02) than patients in Group B. Moreover, the time course of haematocrit showed a significantly higher value at all time points during operation and hospital stay in the group B (P<0.02); similarly, platelet count at ICU arrival was significantly higher in the study group (143±27 x109/L vs. 121±39 x 109/L, P=0.05). Peak postoperative cTroponinI release was significantly lower in the study group (4.74±2.82 vs. 8.43±6.35 ng/dl, P=0.033). Conclusions: The MECC system is suitable for aortic valve replacement and provides better clinical results in terms of need for blood products, platelets consumption and myocardial damage as compared to standard cardiopulmonary bypass.
Department of Cardiothoracic Surgery, Klinikum Braunschweig, Braunschweig, Germany Objectives: Minimised closed-loop perfusion circuits (MPC) were found to reduce side effects of standard extracorporeal circulation (ECC). We evaluated the safety and efficacy of the new ROCsafe®-MPC for aortic valve operations and aortic root surgery. Methods: Eighty patients were randomised for surgery using either MPC [n=40 (14 female/26 male), AVR: n=11, AVR+CABG: n=20, David operation: n=2, aortic root replacement (ARR): n=7, mean age: 72.7±9.4 years] or ECC [n=40 (10 female/30 male), AVR: n=14, AVR+CABG: n=17, David operation: n=1, ARR: n=8, mean age: 68.9±10.0 years]. Neurological status, length of ICU-stay, C-reactive-protein (CRP), serum creatinine, blood count and transfusion requirements were analysed. The MPC included a new ultrasound controlled de-airing unit and was supplemented with a roller pump and a flexible reservoir for LV-venting. As a control we used a standard ECC with centrifugal pump, cardiotomy suction and hard shell reservoir. Results: No deaths or relevant neurological complications occurred. Cross-223119±41; ECC: 120±43 min) were comparable between groups. ICU stay (MPC: 1.8±1.3 vs. ECC: 2.0±1.3 days [P=0.06]), transfusion requirements (Packed red blood cells: MPC: 1.5±0.3 vs. ECC: 2.4±0.4 units/48 h [P=0.02], frozen plasma: MPC: 1.4±0.4 vs. ECC: 1.8±0.4 units/48 h [P=0.04]) and postoperative (48 h) CRP levels (MPC: 74.6±30.7 vs. ECC: 111.6±85 mg/l [P=0.04]) were markedly lower using MPC compared to ECC. Creatinine remained stable in both groups. Conclusions: The ROCsafe®-MPC provides safe circulatory support for a wide range of aortic valve surgery. Transfusion requirements and early inflammatory response were decreased compared to a standard perfusion circuit.
Cardiac Surgery Unit, Magna Graecia University, Catanzaro, Italy Objectives: Linear flows and foreign surfaces activate coagulation and fibrinolysis during cardiopulmonary bypass (CPB). We evaluated whether IABP-induced pulsatile flow modifies haemocoagulative response to CPB. Methods: Between April 2004 and February 2006, 48 patients undergoing preoperative IABP were randomised to non-pulsatile CPB with IABP discontinued during cardioplegic arrest (24 patients; Group A) or IABP-induced pulsatile CPB (automatic 80 bpm; 24 patients Group B). White-blood cells (WBC), haematocrit, platelets, INR, fibrinogen, aPTT were measured at the end of surgery (ES) and postoperatively. Chest drainage, need for re-exploration, transfusions were compared. Results: Perioperative mortality, morbidity, and incidence of re-exploration were comparable (P=NS). Group B showed lower chest drainage (1st day 386.4±292.3 ml vs. 681.9±265.7; P=0.038; 2nd day 282.5±206.7 vs. 485.3±237.4; P=0.044), transfusions (1.6±1.7 units/pt vs. 2.6±2.2; P=0.031), WBC (ES 7170.3±2650.2/µl vs. 9810.0±2540.6; 12 h, 9580.5±323.2 vs. 12030.1±2580.1; 24 h 11157.8±2650.4 vs. 14682.6±1986.9; 48 h, 12260.7±3951.3 vs. 15680.0±3179.5; P<0.05) and INR (ES 1.04±0.65 vs. 1.70±0.1; 12 h, 1.30±0.16 vs. 2.13±0.13; 24 h, 1.13±0.15 vs. 1.45±0.23; 48 h, 1.21±0.09 vs. 1.47±0.13; P<0.05). Moreover, Group B demonstrated higher haematocrit (ES 34.1±4.3 g/dl vs. 27.4±4.9; 12 h 31.6±3.3 vs. 26.8±9.2; P<0.05), platelets (ES 172.9±48.5 min, 103/µl vs. 103.7±22.9; 12 h, 189.1±71.2 vs. 121.9±41.2; 24 h, 232.6±78.9 vs. 115.7±48.7; 48 h, 201.4±68.4 vs. 140.2±89.1; P<0.05), fibrinogen (ES 337.2±53.4 mg/dl vs. 274.6±83.7; 12 h, 352.4±66.6 vs. 277.9±59.3; 24 h, 376.8±65.2 vs. 311.4±98.8; P<0.05), and aPTT (ES 40.5±5.6 s vs. 51.3±6.6; 12 h, 49.4±14.3 vs. 57.2±13.6; 24 h, 44.3±13.6 vs. 57.5±9.4; 48 h, 37.5±5.5 vs. 44.9±7.3; P<0.05). Conclusions: Whenever IABP is inserted preoperatively it should be left on, during cross-clamp time, in order to reduce coagulative and fibrinolytic response to CPB.
Department of Cardiovascular Surgery at Heart Centre Brandenburg, Bernau, Germany Objectives: Modern minimised extracorporeal circulation units (MECU) are currently thoroughly investigated. The propagated advantages against standard extracorporeal circulation (ECC) are reduced foreign body surfaces, decreased inflammation and less micro-bubbles formation. Objective of this study was to compare micro-bubble formation in ECC and MECU. Methods: Each 20 patients underwent isolated coronary artery revascularisation utilising either conventional ECC or MECU (ECCOTM). Patients received a two-stage venous catheter and open, passive venous return into a reservoir. The venous line was deaired prior to initiation of circulatory support. The number of micro bubbles (0–250 mm in size) was counted in the venous and the arterial line of the ECC utilising a commercial bubble counter. Results: All patients underwent uneventful surgery with a normal postoperative course. Compared to the ECC group the MECU group revealed a significantly lower number of micro-bubbles in the venous line (8036±8174 vs. 55,107±62,960; P=0.001). The clinically relevant micro-bubbles in the arterial line, however, did not differ significantly (10,937±17,843 vs. 13,023±24,331; P=0.3901). Conclusions: Minimised extracorporeal circulation units produce less micro-bubbles compared to standard ECC. However, patients treated with conventional ECC are not jeopardised by the elevated micro-bubble load as the majority of these are captured in the integrated arterial filters.
1Department of Cardiovascular Surgery, University Hospital, Freiburg, Germany; 2Department of Anaesthesiology, University Hospital, Freiburg, Germany Objectives: Pulmonary complications are frequent after operations employing cardiopulmonary bypass (CPB), which is presumably linked to a CPB-associated inflammatory reaction. We demonstrated before that perfusion of lung tissue during CPB is significantly reduced, rendering the lung ischaemic. We now tested the hypothesis that avoiding ischaemia of the lung during CPB by direct perfusion of the pulmonary artery decreases the CPB-associated inflammatory response.
Methods: Pigs were placed on cardiopulmonary bypass for 120 min followed by 120 min of reperfusion. In separate groups, pulmonary perfusion was performed pulsatile or non-pulsatile by infusing 20% of the systemic extracorporeal flow into the pulmonary artery. Sham operated animals were used as control. As early inflammatory markers, we assessed the activation of the transcription factors NF-
Results: CPB without pulmonary perfusion induced significant increases in IL-1, IL-6 and TNF-a expression. NF-
Conclusions: The results suggest that pulmonary perfusion reduces the inflammatory response of the lungs during CPB. This effect is greatest with pulsatile pulmonary perfusion. The reduction in cytokine expression by pulmonary perfusion is primarily not NF-
Department of Cardiothoracic Surgery, J W Goethe University, Frankfurt, Germany Objectives: Lung injury is a serious complication after surgery with CPB, especially in high risk patients with impaired pulmonary function. We assessed the protective effect of intermittent hypothermic pulmonary perfusion during CPB on postoperative lung function. Methods: Thirty-one consecutive patients with complex cardiac disease and impaired pulmonary function were enrolled in this study. Eight patients underwent CABG (FEV1: 1.2 (48%), CPB 120 min) and 23 received combined procedures (FEV1: 1.7 (70%), CPB 158 min). Every 20 min after cardioplegia, lungs were perfused with 3 l of hypothermic (20 °C) venous blood through a cannula in the pulmonary artery. During cardioplegia, a PEEP of 14 cm H2O was maintained. Respiratory index (PO2/FiO2) and alveolar-arterial oxygen gradient (AaDO2) were evaluated after induction of anaesthesia, at the end of operation, 6 and 12 h postoperatively. Results: Respiratory index and AaDO2 increased at the end of the operation from 3.5 to 3.9 and from 160 to 193 mmHg, respectively. 48% of the patients were extubated within 6 h postoperatively. Measured respiratory index and AaDO2 of those who still intubated was 2.8 and 126 mmHg. Twelve hours after surgery, 22 patients (72%) were free from ventilatory support. Respiratory index and AaDO2 of still intubated patients was 2.5 and 160 mmHg respectively. None of the primary extubated patients had to be reintubated. Three patients died on ICU due to MOF, sepsis or pneumonia. Conclusions: Hypothermic lung perfusion preserved perioperative pulmonary oxygen exchange in this high risk collective. This is in contrast to reports (Sievers) describing significant deterioration even in normal patients after CPB.
161 - I IMPACT OF THE EUROPEAN WORKING TIME DIRECTIVE ON EXPOSURE TO OPERATIVE CARDIAC SURGICAL TRAINING A. Ali, E. Lim, S. Tsui, Consultants and SpRs 2003–2005 Papworth Hospital, Cambridge, UK Objectives: To |
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Monday 11 September 2006...
Monday 11 September 2006...
650 pg/ml serum VEGF had 83% sensitivity and 77% specificity to identify PGD Grade 3 vs. Grade 0 (P=0.005). 
5 cm) left anterior thoracotomy. Fluroscopy and transoesephageal echocardiography were used for positioning of the valve at aortic annulus. Rapid (160–200 beats/min) ventricular pacing was used to decrease forward flow during balloon valvuloplasty and deployment of a 26 mm Cribier-Edwards Pericardial Valve TM (Edwards Lifescience Inc., Irvin, CA) through the apex of the LV. Single lung ventilation was not required during the procedure. 
4 ng/ml (n=14) were free from rejection. In CyA-patients 55 out of 271 biopsies showed rejection, in TAC-patients 17 out of 125, and in EVL-patients 3 out of 52. MMP-1 serum concentrations 
2 test). 
B and AP-1 by electrophoretic mobility shift assay (EMSA) and quantified their target gene-expression for IL-1, IL-6, and TNF–a by Northern Blot and ELISA.